{ "hospital_name": "Cypress Pointe Surgical Hospital", "last_updated_on": "2026-07-17", "version": "3.0.0", "location_name": [ "Cypress Pointe Surgical Hospital" ], "hospital_address": [ "42570 South Airport Road, Hammond, LA 70403" ], "license_information": { "state": "LA", "license_number": "690" }, "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.\nThis hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount.\nFor 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": "Paolo Zambito" }, "type_2_npi": [ "1790094985" ], "standard_charge_information": [ { "description": "PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR", "code_information": [ { "code": "41", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 28490, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16490.25 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14245.28 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 15969.58 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 18077.71 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14245.28 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17806.6, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14245 }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17236.7888 }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13960, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "per diem", "standard_charge_dollar": 2300 }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14245, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22792, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14591 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14245 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 22093 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1173.72, "maximum": 22792 } ] }, { "description": "PRIVATE ROOM WING A", "code_information": [ { "code": "110", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "gross_charge": 2243.8, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1065.81, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1009.71 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1121.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1009.71 } ], "minimum": 1009.71, "maximum": 1173.72 } ] }, { "description": "CANNULA CO2 ADLT NASAL 7' MCKESSON", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.46, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.54, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.357 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.73 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.357 } ], "minimum": 3.357, "maximum": 3.73 } ] }, { "description": "NOZIN NASAL SWAB", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.36, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.92, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.662 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.18 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.662 } ], "minimum": 4.662, "maximum": 5.18 } ] }, { "description": "OXYGEN EA ADD 4 HOURS", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 67.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 32.11, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 30.42 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 33.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 30.42 } ], "minimum": 30.42, "maximum": 33.8 } ] }, { "description": "CIRCUIT ANESTHESIA LIMBO MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 32.16, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 15.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 14.472 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.08 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.472 } ], "minimum": 14.472, "maximum": 16.08 } ] }, { "description": "GROUNDING PAD SPLIT FOR RF PROCEDURE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 48, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 22.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 21.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 24 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.6 } ], "minimum": 21.6, "maximum": 24 } ] }, { "description": "SCD EXPRESS SLEEVE KNEE MED", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.72, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 22.824 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.36 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.824 } ], "minimum": 22.824, "maximum": 25.36 } ] }, { "description": "COLD COMPRESS INST 6 X9 LF MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.76, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.72 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.72 } ], "minimum": 0.72, "maximum": 0.8 } ] }, { "description": "NASAL CANNULA ADLT CURV 7'", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.88, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.89, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.846 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.94 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.846 } ], "minimum": 0.846, "maximum": 0.94 } ] }, { "description": "CUP DENTURE TEAL W/O PAQ LID MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 0.72, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.34, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.324 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.36 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.324 } ], "minimum": 0.324, "maximum": 0.36 } ] }, { "description": "MANUAL SPIROMETER AIRLIFE SINGLE MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.978 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.42 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.978 } ], "minimum": 3.978, "maximum": 4.42 } ] }, { "description": "URINAL W/TRANSPARENT LID", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.64, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.78, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.738 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.82 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.738 } ], "minimum": 0.738, "maximum": 0.82 } ] }, { "description": "BLANKET LOWER BODY BAIR HUGGER MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.12, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.08, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.604 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.56 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.604 } ], "minimum": 8.604, "maximum": 9.56 } ] }, { "description": "SLIPPER TERRY SOCK XL MEDL", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.1, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.945 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.05 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.945 } ], "minimum": 0.945, "maximum": 1.05 } ] }, { "description": "SLIPPER TERRY SOCK BLUE LG ADLT MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.07, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.98, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.9315 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.035 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.9315 } ], "minimum": 0.9315, "maximum": 1.035 } ] }, { "description": "AIRWAY BERMAN 90MM", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 0.92, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.44, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.414 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.46 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.414 } ], "minimum": 0.414, "maximum": 0.46 } ] }, { "description": "GRADUATE TRIANGLE CONTAINER", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.08, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.486 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.54 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.486 } ], "minimum": 0.486, "maximum": 0.54 } ] }, { "description": "PREP PAD BLUE KIMBERLY CLARK MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.86, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.31, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.187 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.43 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.187 } ], "minimum": 2.187, "maximum": 2.43 } ] }, { "description": "SPONGE GAUZE 8X4 MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.67, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.63 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.7 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.63 } ], "minimum": 0.63, "maximum": 0.7 } ] }, { "description": "CONTAINER SPCMN COMMODE HAT", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.66, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.79, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.747 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.83 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.747 } ], "minimum": 0.747, "maximum": 0.83 } ] }, { "description": "CLEANSER HIBICLENS 4OZ MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.48, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.98, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.716 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.24 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.716 } ], "minimum": 4.716, "maximum": 5.24 } ] }, { "description": "BASIN EMESIS MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 0.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.15, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.144 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.144 } ], "minimum": 0.144, "maximum": 0.16 } ] }, { "description": "SOLUTION PVP", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.85, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.1825 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.425 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.1825 } ], "minimum": 2.1825, "maximum": 2.425 } ] }, { "description": "SLIPPER SOCK 2XL GRAY", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.22, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.999 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.11 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.999 } ], "minimum": 0.999, "maximum": 1.11 } ] }, { "description": "LMA-SUPREME SZ 3 AMBU", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 33.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.06, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.21 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.21 } ], "minimum": 15.21, "maximum": 16.9 } ] }, { "description": "OXYGEN INITIAL 4 HOURS", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 270.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 128.44, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 121.68 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 135.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 121.68 } ], "minimum": 121.68, "maximum": 135.2 } ] }, { "description": "STOCKING ANTI-EMBOL KNEE LRG MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.24, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.34, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.058 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.62 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.058 } ], "minimum": 5.058, "maximum": 5.62 } ] }, { "description": "TOOTHBRUSH TUFT MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 0.16, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.08, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.072 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.08 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.072 } ], "minimum": 0.072, "maximum": 0.08 } ] }, { "description": "TOOTHPASTE MORNING FRESH 1.5OZ", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.24, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.558 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.62 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.558 } ], "minimum": 0.558, "maximum": 0.62 } ] }, { "description": "STOCKING ANTI-EMBOL KNEE XLRG MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.25, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.34, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.0625 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.625 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.0625 } ], "minimum": 5.0625, "maximum": 5.625 } ] }, { "description": "ICE BAG TIE CLOSURE MCK", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.556 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.84 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.556 } ], "minimum": 2.556, "maximum": 2.84 } ] }, { "description": "DRAPE 1015 NONSTERILE 3M", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.16, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.83, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.572 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.08 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.572 } ], "minimum": 4.572, "maximum": 5.08 } ] }, { "description": "ENDOSCOPE TRANSPORT PADS 00052", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.15 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.15 } ], "minimum": 3.15, "maximum": 3.5 } ] }, { "description": "STOCKING ANTI-EMBOL KNEE MED MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.24, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.34, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.058 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.62 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.058 } ], "minimum": 5.058, "maximum": 5.62 } ] }, { "description": "CANNULA CO2 ADLT NASAL 13'", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.88, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.626 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.14 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.626 } ], "minimum": 4.626, "maximum": 5.14 } ] }, { "description": "BEDPAN FRACTURE MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.3, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.57, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.485 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.65 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.485 } ], "minimum": 1.485, "maximum": 1.65 } ] }, { "description": "NEBULIZER OPTI-MIST CLR 7'TB", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.89 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.89 } ], "minimum": 1.89, "maximum": 2.1 } ] }, { "description": "BAG DRAIN CYSTO MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 10.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9.72 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.72 } ], "minimum": 9.72, "maximum": 10.8 } ] }, { "description": "CPM PATIENT KIT OPTIFLEX FLEECE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 109.12, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 51.83, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 49.104 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 54.56 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 49.104 } ], "minimum": 49.104, "maximum": 54.56 } ] }, { "description": "ETT CUFF 6.5MM W/STYLETTE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.94, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.68 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.68 } ], "minimum": 4.68, "maximum": 5.2 } ] }, { "description": "SCRUB PVP PRE 4OZ MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.04, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.34, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.168 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.52 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.168 } ], "minimum": 3.168, "maximum": 3.52 } ] }, { "description": "EYEWEAR SOLARETTES", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.12, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.01, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.954 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.06 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.954 } ], "minimum": 0.954, "maximum": 1.06 } ] }, { "description": "FLOOR SUCTION MAT ECOSUCTIONER ARTHREX", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 160, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 76, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 72 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 80 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 72 } ], "minimum": 72, "maximum": 80 } ] }, { "description": "ISOLATION GOWN BLUE MCK", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.41, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.62, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.5345 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.705 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.5345 } ], "minimum": 1.5345, "maximum": 1.705 } ] }, { "description": "BEDPAN STACK GRAY", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.73, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.2285 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.365 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.2285 } ], "minimum": 1.2285, "maximum": 1.365 } ] }, { "description": "AEROSOL MASK ELONG ADLT NO TUB", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.52, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.684 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.76 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.684 } ], "minimum": 0.684, "maximum": 0.76 } ] }, { "description": "AIRWAY BERMAN 80MM", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.04, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.49, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.468 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.52 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.468 } ], "minimum": 0.468, "maximum": 0.52 } ] }, { "description": "POSITIONER HEAD ADLT", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.37, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.14 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.14 } ], "minimum": 4.14, "maximum": 4.6 } ] }, { "description": "SCD EXPRESS SLEEVE KNEE LARGE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 72.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 34.41, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 32.598 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 36.22 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 32.598 } ], "minimum": 32.598, "maximum": 36.22 } ] }, { "description": "SCD EXPRESS SLEEVE KNEE XL", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.72, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 47.84, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 45.324 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 50.36 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 45.324 } ], "minimum": 45.324, "maximum": 50.36 } ] }, { "description": "STOCKING ANTI-EMB KNEE HIGH XX-LRG", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.26, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.35, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.067 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.63 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.067 } ], "minimum": 5.067, "maximum": 5.63 } ] }, { "description": "ENDO SURGICAL MOUTHPIECE ADULT BOSTON S", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.38, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.13, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.071 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.19 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.071 } ], "minimum": 1.071, "maximum": 1.19 } ] }, { "description": "CRUTCH ADULT TALL MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 51.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.36, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 23.076 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.076 } ], "minimum": 23.076, "maximum": 25.64 } ] }, { "description": "CIRCUIT ANESTHESIA LIMBO PED W/SAMP LINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17.96, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 8.53, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.082 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.98 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.082 } ], "minimum": 8.082, "maximum": 8.98 } ] }, { "description": "BAG URINARY DRAIN 2000 ML", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.24, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.91, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.708 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.12 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.708 } ], "minimum": 3.708, "maximum": 4.12 } ] }, { "description": "HYDROGEN PEROXIDE 4 OZ", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.76, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.79, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.692 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.88 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.692 } ], "minimum": 1.692, "maximum": 1.88 } ] }, { "description": "HEADREST PILLOW PRONE POSTION", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 48.64, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 23.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 21.888 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 24.32 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.888 } ], "minimum": 21.888, "maximum": 24.32 } ] }, { "description": "MOUTH WASH MINT N AL 4OZ", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.9 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.9 } ], "minimum": 0.9, "maximum": 1 } ] }, { "description": "ELECTRODE QUICK COMBO ADLT UNIV", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 129.08, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.31, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 58.086 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 64.54 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 58.086 } ], "minimum": 58.086, "maximum": 64.54 } ] }, { "description": "STERILE SLEEVE DISPOSABLE CARDINAL", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.72, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.29, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.224 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.36 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.224 } ], "minimum": 1.224, "maximum": 1.36 } ] }, { "description": "SUCTION POLYP TRAP EZEM", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14.17, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.73, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.3765 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.085 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.3765 } ], "minimum": 6.3765, "maximum": 7.085 } ] }, { "description": "STOCKING ANTI-EMB THIGH XL/RG", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.08, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.494 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.66 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.494 } ], "minimum": 10.494, "maximum": 11.66 } ] }, { "description": "AIRWAY NASOPHARY 8.0MM", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9.72, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.62, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.374 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.86 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.374 } ], "minimum": 4.374, "maximum": 4.86 } ] }, { "description": "TED HOSE ANTI-EMBOLISM STOCKING XXL MCK", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 30.64, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 14.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 13.788 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.32 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.788 } ], "minimum": 13.788, "maximum": 15.32 } ] }, { "description": "ARMBOARD WRIST ARTERIAL CARDINAL", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.42, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.22, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.739 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.71 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.739 } ], "minimum": 8.739, "maximum": 9.71 } ] }, { "description": "MASK ANES FLEX TODDLER MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.14, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.97 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.97 } ], "minimum": 2.97, "maximum": 3.3 } ] }, { "description": "STOCKING ANTI-EMB THIGH LRG", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.08, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.494 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.66 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.494 } ], "minimum": 10.494, "maximum": 11.66 } ] }, { "description": "RESTRAINT WRIST DISP MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9.64, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.58, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.338 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.82 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.338 } ], "minimum": 4.338, "maximum": 4.82 } ] }, { "description": "SCD FOOT CUFF MEDIUM", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 32.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 30.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 34 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 30.6 } ], "minimum": 30.6, "maximum": 34 } ] }, { "description": "ATHLETIC SUPPORTER EZ WRAP LARGE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 27.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.22, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 12.528 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.92 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.528 } ], "minimum": 12.528, "maximum": 13.92 } ] }, { "description": "STOCKING ANTI-EMB REG KNEE XXX-LRG MEDL", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.07, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.806 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.34 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.806 } ], "minimum": 4.806, "maximum": 5.34 } ] }, { "description": "MASK TENT FACE ADLT 6' AEROSOL TB", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.22, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.106 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.34 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.106 } ], "minimum": 2.106, "maximum": 2.34 } ] }, { "description": "KNEE IMMOBILIZER NONHINGED XLARGE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 61.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 29.11, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 27.576 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 30.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 27.576 } ], "minimum": 27.576, "maximum": 30.64 } ] }, { "description": "RAZOR DISP SHAVE PREP DBL EDGE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 0.78, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.37, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.351 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.39 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.351 } ], "minimum": 0.351, "maximum": 0.39 } ] }, { "description": "MASK ANES FLEX CHLD", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.72, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.19, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.024 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.36 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.024 } ], "minimum": 3.024, "maximum": 3.36 } ] }, { "description": "TUBE ENDOTRACH CUFF W/STYLETTE 6.0MM", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.69 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.69 } ], "minimum": 3.69, "maximum": 4.1 } ] }, { "description": "DEODORANT ROLL ON 1.5 OZ MCK", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.16, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.422 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.58 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.422 } ], "minimum": 1.422, "maximum": 1.58 } ] }, { "description": "MASK ANES AMBU FLEX PEDI SZ2 MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.06 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.06 } ], "minimum": 3.06, "maximum": 3.4 } ] }, { "description": "CRUTCH YOUTH", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 52.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 25.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 23.778 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.42 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.778 } ], "minimum": 23.778, "maximum": 26.42 } ] }, { "description": "BAG BREATHING 2L LF", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17.93, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 8.52, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.0685 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.965 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.0685 } ], "minimum": 8.0685, "maximum": 8.965 } ] }, { "description": "PRONE POSITIONING ARM CRADLES", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 8.27, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7.83 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.7 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.83 } ], "minimum": 7.83, "maximum": 8.7 } ] }, { "description": "AMBU MASK RESUSITATOR ADLT", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 34.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.53, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.66 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.66 } ], "minimum": 15.66, "maximum": 17.4 } ] }, { "description": "EXTENSION SET KING F2", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.57, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.45, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.1065 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.785 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.1065 } ], "minimum": 6.1065, "maximum": 6.785 } ] }, { "description": "AIRWAY BERMAN 70MM", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.08, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.486 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.54 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.486 } ], "minimum": 0.486, "maximum": 0.54 } ] }, { "description": "ARMBOARD WRIST FOAM DISP 3 X9", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.19, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.57, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.5355 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.595 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.5355 } ], "minimum": 0.5355, "maximum": 0.595 } ] }, { "description": "GAS SAMPLE LINEW/MALE CONN 10'", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.52, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.57, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.384 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.76 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.384 } ], "minimum": 3.384, "maximum": 3.76 } ] }, { "description": "ATHLETIC SUPPORTER EZ WRAP MEDIUM", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 10.24, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9.702 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.78 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.702 } ], "minimum": 9.702, "maximum": 10.78 } ] }, { "description": "ATHLETIC SUPPORTER EZ WRAP X-LARGE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 27.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.22, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 12.528 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.92 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.528 } ], "minimum": 12.528, "maximum": 13.92 } ] }, { "description": "STOCKING ANTI-EMB THIGH MED", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 22.76, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 10.81, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.242 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.38 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.242 } ], "minimum": 10.242, "maximum": 11.38 } ] }, { "description": "TUBING OXY VINYL TIP 14' MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.16, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.422 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.58 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.422 } ], "minimum": 1.422, "maximum": 1.58 } ] }, { "description": "URINE STRAINER MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.39, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.66, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.6255 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.695 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.6255 } ], "minimum": 0.6255, "maximum": 0.695 } ] }, { "description": "PLASTER ROLL 4 MCKESSON", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.48, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.08, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.916 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.24 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.916 } ], "minimum": 2.916, "maximum": 3.24 } ] }, { "description": "BANDAGE ESMARK 4 X3YDS DEROYAL MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.12, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.38, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.204 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.56 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.204 } ], "minimum": 3.204, "maximum": 3.56 } ] }, { "description": "RENTAL FEE FOR QUADRANT SETUP", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6000, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2850, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2700 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2700 } ], "minimum": 2700, "maximum": 3000 } ] }, { "description": "STOCKING ANTI-EMBOL KNEE SM MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15.16, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 7.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.822 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.58 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.822 } ], "minimum": 6.822, "maximum": 7.58 } ] }, { "description": "SHOE POST OP MALE SM DARCO MEDL", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 39.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 18.79, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 17.802 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.78 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.802 } ], "minimum": 17.802, "maximum": 19.78 } ] }, { "description": "MASK OXY HI CONC N/REB ELONG 7' TU", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.83, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.24, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.0735 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.415 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.0735 } ], "minimum": 3.0735, "maximum": 3.415 } ] }, { "description": "CARAFE HANDLE QT GRAPHITE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.03, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.49, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.4635 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.515 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.4635 } ], "minimum": 0.4635, "maximum": 0.515 } ] }, { "description": "PEDIATRIC GROUNDING PAD MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.88, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9.36 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.36 } ], "minimum": 9.36, "maximum": 10.4 } ] }, { "description": "TUBE EXTENDABLE MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.66, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.74, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.647 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.83 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.647 } ], "minimum": 1.647, "maximum": 1.83 } ] }, { "description": "SUTURE PDS II 5-0 18IN PS-2", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.676 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.676 } ], "minimum": 8.676, "maximum": 9.64 } ] }, { "description": "WALKING BOOT LARGE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 130.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 62.07, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 58.806 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 65.34 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 58.806 } ], "minimum": 58.806, "maximum": 65.34 } ] }, { "description": "KNEE IMMOBILIZER HINGED II SHORT HOOK", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 160.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 76.13, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 72.126 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 80.14 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 72.126 } ], "minimum": 72.126, "maximum": 80.14 } ] }, { "description": "NEBULIZER ADAPTER FOR AQUAPAK WATER", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9.94, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.473 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.97 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.473 } ], "minimum": 4.473, "maximum": 4.97 } ] }, { "description": "CRUTCH STEEL 350LB CAP TALL ADULT", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 45.72, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 20.574 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.86 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.574 } ], "minimum": 20.574, "maximum": 22.86 } ] }, { "description": "FILTER VENT BACTERIA", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.35, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.278 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.42 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.278 } ], "minimum": 1.278, "maximum": 1.42 } ] }, { "description": "STOCKING ANTI-EMB THIGH SMALL", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 22.76, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 10.81, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.242 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.38 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.242 } ], "minimum": 10.242, "maximum": 11.38 } ] }, { "description": "SPLINT WRIST CTS RIGHT XLG", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 27.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.22, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 12.528 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.92 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.528 } ], "minimum": 12.528, "maximum": 13.92 } ] }, { "description": "SPLINT WRIST CTS LEFT MED", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 27.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 12.348 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.348 } ], "minimum": 12.348, "maximum": 13.72 } ] }, { "description": "AIRWAY BERMAN 60MM", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.04, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.49, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.468 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.52 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.468 } ], "minimum": 0.468, "maximum": 0.52 } ] }, { "description": "SHOULDER IMMOBILIZER LARGE MED", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 41.24, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 19.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 18.558 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.62 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.558 } ], "minimum": 18.558, "maximum": 20.62 } ] }, { "description": "SLIPPER TERRY PERFM LT BLUE YTH", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.8 } ], "minimum": 1.8, "maximum": 2 } ] }, { "description": "AIRWAY INTUBATION 10.0CM", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15.88, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 7.54, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7.146 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.94 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.146 } ], "minimum": 7.146, "maximum": 7.94 } ] }, { "description": "SPOT GI SUPPLY", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 138, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 65.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 62.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 69 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 62.1 } ], "minimum": 62.1, "maximum": 69 } ] }, { "description": "STERILE LEGGINS DISPOSABLE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14.08, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.69, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.336 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.04 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.336 } ], "minimum": 6.336, "maximum": 7.04 } ] }, { "description": "BIPAP VISION DISPOSABLE CIRCUIT", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 25.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.97, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 11.34 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.34 } ], "minimum": 11.34, "maximum": 12.6 } ] }, { "description": "SHAMPOO NO RINSE CARDINAL", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.04, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.44, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.368 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.52 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.368 } ], "minimum": 1.368, "maximum": 1.52 } ] }, { "description": "KNEE IMMOBILIZER NONHINGED SMALL", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 54.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 25.86, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 24.498 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 27.22 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 24.498 } ], "minimum": 24.498, "maximum": 27.22 } ] }, { "description": "EGGCRATE OVERLAY 72 X 34 X 4 CARDINAL", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 70.72, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 33.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 31.824 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 35.36 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 31.824 } ], "minimum": 31.824, "maximum": 35.36 } ] }, { "description": "MASK ANES FLEX PEDIATRIC SZ1 MEDLINE", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.402 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.78 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.402 } ], "minimum": 3.402, "maximum": 3.78 } ] }, { "description": "SCD FOOT CUFF LARGE CARDINAL", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 92.48, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 43.93, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 41.616 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 46.24 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 41.616 } ], "minimum": 41.616, "maximum": 46.24 } ] }, { "description": "PERINEAL CLEANSER 4 OZ SPRAY", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.58, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.448 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.448 } ], "minimum": 2.448, "maximum": 2.72 } ] }, { "description": "HOLMIUM LASER CANCELLATION POST SET UP", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1680, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 798, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 756 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 840 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 756 } ], "minimum": 756, "maximum": 840 } ] }, { "description": "HOLMIUM LASER HIGH POWER AGILITI", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3360, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1596, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1512 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1680 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1512 } ], "minimum": 1512, "maximum": 1680 } ] }, { "description": "PREMIUM STONE TREATMENT AGILITI", "code_information": [ { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3980, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1890.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1791 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1990 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1791 } ], "minimum": 1791, "maximum": 1990 } ] }, { "description": "SPLINT SCOTCHCAST ONE STEP 4 X30 MEDLIN", "code_information": [ { "code": "271", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 49.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 23.66, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 22.41 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 24.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.41 } ], "minimum": 22.41, "maximum": 24.9 } ] }, { "description": "ARM SLING W/PAD STRAP LG MEDLINE", "code_information": [ { "code": "271", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.644 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.644 } ], "minimum": 4.644, "maximum": 5.16 } ] }, { "description": "SHOE POST OP FEMALE LG DARCO MEDL", "code_information": [ { "code": "271", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 34.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.444 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.444 } ], "minimum": 15.444, "maximum": 17.16 } ] }, { "description": "ARM SLING W/PAD STRAP XL MEDLINE", "code_information": [ { "code": "271", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.52, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.734 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.26 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.734 } ], "minimum": 4.734, "maximum": 5.26 } ] }, { "description": "SHOE POST OP MALE LG DARCO MEDL", "code_information": [ { "code": "271", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 34.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.444 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.444 } ], "minimum": 15.444, "maximum": 17.16 } ] }, { "description": "SHOULDER IMMOBOLIZER UNIVERSAL MED", "code_information": [ { "code": "271", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 122.04, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 57.97, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 54.918 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 61.02 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 54.918 } ], "minimum": 54.918, "maximum": 61.02 } ] }, { "description": "SHOE POST OP FEMALE MED DARCO MEdLINE", "code_information": [ { "code": "271", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 34.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.444 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.444 } ], "minimum": 15.444, "maximum": 17.16 } ] }, { "description": "SHOE POST OP MALE MED DARCO MEDLI", "code_information": [ { "code": "271", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 34.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.444 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.444 } ], "minimum": 15.444, "maximum": 17.16 } ] }, { "description": "ARM SLING W/PAD STRAP MEDLINE", "code_information": [ { "code": "271", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.644 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.644 } ], "minimum": 4.644, "maximum": 5.16 } ] }, { "description": "TRANSMITTER ADAPTER ST JUDE", "code_information": [ { "code": "271", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1580, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 750.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 711 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 790 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 711 } ], "minimum": 711, "maximum": 790 } ] }, { "description": "SHOE POST OP MALE XLG DARCO", "code_information": [ { "code": "271", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 32.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 15.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 14.49 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.49 } ], "minimum": 14.49, "maximum": 16.1 } ] }, { "description": "CERVICAL COLLAR MED FORM FIT PROCARE", "code_information": [ { "code": "271", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.32, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.04 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.04 } ], "minimum": 5.04, "maximum": 5.6 } ] }, { "description": "BINDER ABDN 3 PANEL UNIV 30 -45", "code_information": [ { "code": "271", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 63.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 30.25, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 28.656 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 31.84 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 28.656 } ], "minimum": 28.656, "maximum": 31.84 } ] }, { "description": "CERVICAL COLLAR LG FORM FIT PROCARE CAR", "code_information": [ { "code": "271", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.778 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.42 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.778 } ], "minimum": 5.778, "maximum": 6.42 } ] }, { "description": "BINDER ABDN 4 PANEL UNIV 30-45 MEDLINE", "code_information": [ { "code": "271", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 25.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 12.08, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 11.448 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.448 } ], "minimum": 11.448, "maximum": 12.72 } ] }, { "description": "ABD BINDER 30-45 (9 3-PANEL)", "code_information": [ { "code": "271", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 7.89, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7.47 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.47 } ], "minimum": 7.47, "maximum": 8.3 } ] }, { "description": "CERVICAL COLLAR SOFT X-LRG MEDLINE", "code_information": [ { "code": "271", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.6 } ], "minimum": 3.6, "maximum": 4 } ] }, { "description": "CERVICAL COLLAR SM FORM FIT PROCARE", "code_information": [ { "code": "271", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.48, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.45, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.166 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.74 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.166 } ], "minimum": 5.166, "maximum": 5.74 } ] }, { "description": "TRANSMITTER ADAPTER ST JUDE", "code_information": [ { "code": "271", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1600, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 760, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 720 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 800 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 720 } ], "minimum": 720, "maximum": 800 } ] }, { "description": "IV START KIT W/TEGADERM AND CHLOR MEDL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.04, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.44, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.368 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.52 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.368 } ], "minimum": 1.368, "maximum": 1.52 } ] }, { "description": "EXTENSION SET ULTRASITE STD BORE MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.15 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.15 } ], "minimum": 3.15, "maximum": 3.5 } ] }, { "description": "CATHETER IV PROTECT PLUS 22GX1", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.48, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.366 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.74 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.366 } ], "minimum": 3.366, "maximum": 3.74 } ] }, { "description": "PAIN CASE GLOVE CHARGE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.36, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.112 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.68 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.112 } ], "minimum": 5.112, "maximum": 5.68 } ] }, { "description": "CATHETER IV PROTECT PLUS 20GX1", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.48, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.366 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.74 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.366 } ], "minimum": 3.366, "maximum": 3.74 } ] }, { "description": "NEEDLE RF 18G 150MM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 66, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 31.35, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 29.7 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 33 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.7 } ], "minimum": 29.7, "maximum": 33 } ] }, { "description": "IV ADMIN SET SECONDARY 15DRP 40 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.8 } ], "minimum": 1.8, "maximum": 2 } ] }, { "description": "SODIUM CHLORIDE FOR INJECTION 10ML", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.27, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.206 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.34 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.206 } ], "minimum": 1.206, "maximum": 1.34 } ] }, { "description": "EXTENSION SET W/2 ULTRASITE VLV MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.356 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.84 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.356 } ], "minimum": 4.356, "maximum": 4.84 } ] }, { "description": "DRAPE 1/2 SHEET 40X57 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.52, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.15, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.034 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.26 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.034 } ], "minimum": 2.034, "maximum": 2.26 } ] }, { "description": "SPONGE GZE 4 X4 16-42441 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.52, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.684 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.76 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.684 } ], "minimum": 0.684, "maximum": 0.76 } ] }, { "description": "TOWEL OR STR BLUE MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.92, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.29, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.114 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.46 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.114 } ], "minimum": 3.114, "maximum": 3.46 } ] }, { "description": "APPLICATOR CHLORAPREP 3ML", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.35, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.5075 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.675 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.5075 } ], "minimum": 1.5075, "maximum": 1.675 } ] }, { "description": "SAGE WIPE 3 PACK MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9 } ], "minimum": 9, "maximum": 10 } ] }, { "description": "CPT THOMPSON SPINAL TRAY #13-A9093A MEDL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 24.26, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.52, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.917 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.13 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.917 } ], "minimum": 10.917, "maximum": 12.13 } ] }, { "description": "IV ADMIN SET SAFEDAY 15DPM 3PORT MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.88, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.626 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.14 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.626 } ], "minimum": 4.626, "maximum": 5.14 } ] }, { "description": "SOL 0.9% SO CHL IRR 1000ML MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.73, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.52, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.1785 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.865 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.1785 } ], "minimum": 6.1785, "maximum": 6.865 } ] }, { "description": "MINOR CASE GLOVE CHARGE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 26.52, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 12.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 11.934 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.26 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.934 } ], "minimum": 11.934, "maximum": 13.26 } ] }, { "description": "OXI MASK 7' MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.14, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.08 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.08 } ], "minimum": 1.08, "maximum": 1.2 } ] }, { "description": "NEEDLE SPINAL STR 22G X 3 1/2 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.66, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.52 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.52 } ], "minimum": 2.52, "maximum": 2.8 } ] }, { "description": "NEEDLE RF 20G 100MM STRYKER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 66, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 31.35, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 29.7 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 33 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.7 } ], "minimum": 29.7, "maximum": 33 } ] }, { "description": "SKIN MARKER WRITESITE PLUS STERILE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.81, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.1645 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.405 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.1645 } ], "minimum": 2.1645, "maximum": 2.405 } ] }, { "description": "SUCTION TUBING MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.17, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.052 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.28 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.052 } ], "minimum": 2.052, "maximum": 2.28 } ] }, { "description": "ADULT GROUNDING PAD PATIENT RETURN MEDLI", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.43, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.148 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.148 } ], "minimum": 5.148, "maximum": 5.72 } ] }, { "description": "SCTN YANK RGD BULB 16-66202 MCKESSON", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.99, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.8955 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.995 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.8955 } ], "minimum": 0.8955, "maximum": 0.995 } ] }, { "description": "DRAPE C-ARM 3M MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17.35, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 8.24, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7.8075 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.675 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.8075 } ], "minimum": 7.8075, "maximum": 8.675 } ] }, { "description": "NEEDLE RF 18G 100MM STRYKER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 66, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 31.35, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 29.7 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 33 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.7 } ], "minimum": 29.7, "maximum": 33 } ] }, { "description": "CONTAINER SPECIMEN STERILE 4OZ MEDL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 0.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.29, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.27 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.27 } ], "minimum": 0.27, "maximum": 0.3 } ] }, { "description": "GOWN SURGICAL ULTRA LG MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.528 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.92 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.528 } ], "minimum": 3.528, "maximum": 3.92 } ] }, { "description": "DRESSING MEDIUM TELFA STR 8 X3 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 0.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.27, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.252 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.28 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.252 } ], "minimum": 0.252, "maximum": 0.28 } ] }, { "description": "ABD PAD MCKESSON", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 0.81, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.38, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.3645 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.405 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.3645 } ], "minimum": 0.3645, "maximum": 0.405 } ] }, { "description": "PUMP SET UNIV 15DRP MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17.16, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 8.15, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7.722 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.58 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.722 } ], "minimum": 7.722, "maximum": 8.58 } ] }, { "description": "CPT SPINALTRAY DR DOMANGUE MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 43.48, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 20.65, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 19.566 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.74 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.566 } ], "minimum": 19.566, "maximum": 21.74 } ] }, { "description": "SUTURE VICRYL 0 CT-1 POP OFF", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 44.48, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.13, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 20.016 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.24 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.016 } ], "minimum": 20.016, "maximum": 22.24 } ] }, { "description": "BLANKET UPPER BODY ALLIANCE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18.96, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.01, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.532 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.48 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.532 } ], "minimum": 8.532, "maximum": 9.48 } ] }, { "description": "RAPIDVAC SMOKE TUBING W SPONGE GUARD", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 40.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 19.19, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 18.18 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.18 } ], "minimum": 18.18, "maximum": 20.2 } ] }, { "description": "TEGADERM DRESSING 4 X 4-3/4IN", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.57, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.22, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.1565 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.285 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.1565 } ], "minimum": 1.1565, "maximum": 1.285 } ] }, { "description": "SOL .9% SO CHL IR 3000 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 45.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.64, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 20.502 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.78 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.502 } ], "minimum": 20.502, "maximum": 22.78 } ] }, { "description": "SOD CHL IVSOL 0.90% 100ML MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.52, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.33 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.7 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.33 } ], "minimum": 3.33, "maximum": 3.7 } ] }, { "description": "AIRWAY BERMAN 100MM LF", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 0.88, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.42, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.396 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.44 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.396 } ], "minimum": 0.396, "maximum": 0.44 } ] }, { "description": "SUTURE VICRYL 2-0 SH POP OFF", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.08, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.61, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.686 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.54 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.686 } ], "minimum": 16.686, "maximum": 18.54 } ] }, { "description": "TUBE ENDOTRACH CUFF 7.0 W/STYLE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.41, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.176 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.176 } ], "minimum": 4.176, "maximum": 4.64 } ] }, { "description": "GOWN XL TOGA STRYKER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 389.48, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 185, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 175.266 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 194.74 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 175.266 } ], "minimum": 175.266, "maximum": 194.74 } ] }, { "description": "CHLORAPREP 26 ML MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 25.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 12.07, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 11.43 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.7 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.43 } ], "minimum": 11.43, "maximum": 12.7 } ] }, { "description": "CONTAINER SPECIMEN FOR OR MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.24, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.558 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.62 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.558 } ], "minimum": 0.558, "maximum": 0.62 } ] }, { "description": "BLADE CLIPPER ASSEMBLY MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.12, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.86, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.654 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.06 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.654 } ], "minimum": 3.654, "maximum": 4.06 } ] }, { "description": "STAPLER SKIN PROXI WIDE MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 24.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.98 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.98 } ], "minimum": 10.98, "maximum": 12.2 } ] }, { "description": "PADDING CAST STR 6 X4YDS MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.52, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.834 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.26 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.834 } ], "minimum": 3.834, "maximum": 4.26 } ] }, { "description": "EXT SET SMALL BORE 6 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.52, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.44 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.44 } ], "minimum": 1.44, "maximum": 1.6 } ] }, { "description": "GOWN SURGICAL ULTRA XLG MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.01, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.798 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.22 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.798 } ], "minimum": 3.798, "maximum": 4.22 } ] }, { "description": "NEURO DRILL BIT 3.0 LESS AGGRESSIVE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 448, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 212.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 201.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 224 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 201.6 } ], "minimum": 201.6, "maximum": 224 } ] }, { "description": "BASIN WASH RECTGL 7QT MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.99 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.99 } ], "minimum": 0.99, "maximum": 1.1 } ] }, { "description": "BLADE SURGICAL C/S STR #15 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.57, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.54 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.54 } ], "minimum": 0.54, "maximum": 0.6 } ] }, { "description": "CPT SINGLE SHOT EPIDURAL TRAY DOMANGUE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 51.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.61, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 23.31 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.31 } ], "minimum": 23.31, "maximum": 25.9 } ] }, { "description": "CPT NEURO CUSTOM PK", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 217.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 103.27, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 97.83 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 108.7 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 97.83 } ], "minimum": 97.83, "maximum": 108.7 } ] }, { "description": "DURAPREP SOLUTION 26ML #8630 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16.96, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 8.06, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7.632 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.48 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.632 } ], "minimum": 7.632, "maximum": 8.48 } ] }, { "description": "MASTISOL VIAL TIP CARDINAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.08, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.89, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.736 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.04 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.736 } ], "minimum": 2.736, "maximum": 3.04 } ] }, { "description": "SUTURE REMOVAL KIT #25-5427", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.74, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.702 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.78 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.702 } ], "minimum": 0.702, "maximum": 0.78 } ] }, { "description": "MAJOR CASE GLOVE CHARGE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 67.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 32.15, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 30.456 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 33.84 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 30.456 } ], "minimum": 30.456, "maximum": 33.84 } ] }, { "description": "SUTURE VICRYL 2-0 CT-1", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.58, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.448 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.448 } ], "minimum": 2.448, "maximum": 2.72 } ] }, { "description": "DRAPE LAP T W/ARMBOARD COVERS", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 22.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 10.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.152 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.28 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.152 } ], "minimum": 10.152, "maximum": 11.28 } ] }, { "description": "CPT CUSTOM UROLOGY PACK MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 62.08, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 29.49, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 27.936 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 31.04 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 27.936 } ], "minimum": 27.936, "maximum": 31.04 } ] }, { "description": "STANDARD BATHING CLOTH READYBATH", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.05, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.45, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.3725 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.525 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.3725 } ], "minimum": 1.3725, "maximum": 1.525 } ] }, { "description": "SUTURE VICRYL 3-0 SH POP OFF", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 38.72, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 18.39, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 17.424 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.36 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.424 } ], "minimum": 17.424, "maximum": 19.36 } ] }, { "description": "6 INCH ACE STERILE MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.89 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.89 } ], "minimum": 1.89, "maximum": 2.1 } ] }, { "description": "SUTURE ETHILON 3-0 PS-2 18", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.994 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.66 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.994 } ], "minimum": 5.994, "maximum": 6.66 } ] }, { "description": "STERI STRIP 1/2 X 4 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.36, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.512 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.68 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.512 } ], "minimum": 1.512, "maximum": 1.68 } ] }, { "description": "HEMOVAC KIT 10FR 1/8 PVC DRAIN MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 31.87, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 15.14, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 14.3415 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.935 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.3415 } ], "minimum": 14.3415, "maximum": 15.935 } ] }, { "description": "LMA-SUPREME SZ 4 AMBU", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 33.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.06, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.21 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.21 } ], "minimum": 15.21, "maximum": 16.9 } ] }, { "description": "TRAY FOLEY CATH URINE METER MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 51.88, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.64, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 23.346 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.94 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.346 } ], "minimum": 23.346, "maximum": 25.94 } ] }, { "description": "CYSTOSCOPY TUBING MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.07, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.852 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.28 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.852 } ], "minimum": 3.852, "maximum": 4.28 } ] }, { "description": "BOWL SOLUTION STR 32OZ MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.8 } ], "minimum": 1.8, "maximum": 2 } ] }, { "description": "SMALL TEGADERM 2-3/8 X2-3/4", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.48, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.45 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.45 } ], "minimum": 0.45, "maximum": 0.5 } ] }, { "description": "BOVIE PENCIL MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12.72, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.04, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.724 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.36 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.724 } ], "minimum": 5.724, "maximum": 6.36 } ] }, { "description": "DRAPE 3/4 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9.88, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.69, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.446 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.94 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.446 } ], "minimum": 4.446, "maximum": 4.94 } ] }, { "description": "DORNOCH INTELLICART HIGH FLOW MANIFOLD", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 71, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 33.73, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 31.95 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 35.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 31.95 } ], "minimum": 31.95, "maximum": 35.5 } ] }, { "description": "NEEDLE SPINAL QUINCKE 22GX5 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.64, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.48, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.138 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.82 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.138 } ], "minimum": 6.138, "maximum": 6.82 } ] }, { "description": "PADDING CAST STR 3 X4YDS MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.04, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.77 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.77 } ], "minimum": 4.77, "maximum": 5.3 } ] }, { "description": "COVER LIGHTHANDLE STR LB53A", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.58, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.448 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.448 } ], "minimum": 2.448, "maximum": 2.72 } ] }, { "description": "JACKSON PT CARE KIT WITH PRONEVIEW OSI", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 158.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.24, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 71.28 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 79.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 71.28 } ], "minimum": 71.28, "maximum": 79.2 } ] }, { "description": "DRAPE C ARMOR LATERAL CFI MEDICAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 172.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 81.85, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 77.544 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 86.16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 77.544 } ], "minimum": 77.544, "maximum": 86.16 } ] }, { "description": "1L WATER BAG STERILE L8500", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12.14, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.77, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.463 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.07 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.463 } ], "minimum": 5.463, "maximum": 6.07 } ] }, { "description": "SPONGE KITTNER 9/16X1/4", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.01, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.95, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.9045 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.005 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.9045 } ], "minimum": 0.9045, "maximum": 1.005 } ] }, { "description": "DRES ADAPTIC 3 X3 2012 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 0.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.38, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.36 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.36 } ], "minimum": 0.36, "maximum": 0.4 } ] }, { "description": "CATHETER IV PROTECT PLUS 24GX3/4", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.17, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.006 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.34 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.006 } ], "minimum": 3.006, "maximum": 3.34 } ] }, { "description": "SUTURE VICRYL #1CT J959H", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.66, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.52 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.52 } ], "minimum": 2.52, "maximum": 2.8 } ] }, { "description": "IV ADMIN SET ULTRASITE MICRODRIP 60 MEDL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.76, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.292 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.88 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.292 } ], "minimum": 5.292, "maximum": 5.88 } ] }, { "description": "CATARACT SUPPLY KIT SIGHTPATH MEDICAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2040, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 969, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 918 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1020 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 918 } ], "minimum": 918, "maximum": 1020 } ] }, { "description": "NATURAL BONE WAX STERILE MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14.92, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 7.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.714 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.46 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.714 } ], "minimum": 6.714, "maximum": 7.46 } ] }, { "description": "INSULATED BOVIE TIP MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20.92, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.94, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9.414 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.46 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.414 } ], "minimum": 9.414, "maximum": 10.46 } ] }, { "description": "PEDICLE PROBE MAGSTIM NEURO MONITORING", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 283.98, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 134.89, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 127.791 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 141.99 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 127.791 } ], "minimum": 127.791, "maximum": 141.99 } ] }, { "description": "SINGLE PACK 4 X4 12PLY PERFM MCK", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 0.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.32, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.306 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.34 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.306 } ], "minimum": 0.306, "maximum": 0.34 } ] }, { "description": "CPT EXTREMITY MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 198.64, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.35, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 89.388 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 99.32 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 89.388 } ], "minimum": 89.388, "maximum": 99.32 } ] }, { "description": "GOWN SURGICAL ULTRA 2XL MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15.16, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 7.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.822 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.58 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.822 } ], "minimum": 6.822, "maximum": 7.58 } ] }, { "description": "SUTURE VICRYL SH 3-0 27 3-0", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.77, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.628 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.92 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.628 } ], "minimum": 2.628, "maximum": 2.92 } ] }, { "description": "SCTN YANK RIGID BULB DR HARROD MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.12, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.01, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.954 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.06 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.954 } ], "minimum": 0.954, "maximum": 1.06 } ] }, { "description": "IRR SET TURP/BLADDER Y-TYPE MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.84, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.48 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.48 } ], "minimum": 6.48, "maximum": 7.2 } ] }, { "description": "CELL SAVER-AIS SUCTION LINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 72, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 34.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 32.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 36 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 32.4 } ], "minimum": 32.4, "maximum": 36 } ] }, { "description": "DRESSING ADAPTIC 3 X8 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.88, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.89, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.846 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.94 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.846 } ], "minimum": 0.846, "maximum": 0.94 } ] }, { "description": "AQUAMANTIS 2.3 BIPOLAR SEALER MEDTRONIC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1560, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 741, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 702 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 780 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 702 } ], "minimum": 702, "maximum": 780 } ] }, { "description": "SPHERES STERILE IZI", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 133.12, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 63.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 59.904 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 66.56 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 59.904 } ], "minimum": 59.904, "maximum": 66.56 } ] }, { "description": "PAD EYE OVAL STR 1/8 X2 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 0.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.19, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.18 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.18 } ], "minimum": 0.18, "maximum": 0.2 } ] }, { "description": "DRAPE IOBAN SMALL 6640EZ MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.38, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.048 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.048 } ], "minimum": 6.048, "maximum": 6.72 } ] }, { "description": "CUFF DISP TOURNIQUET 34 X 4 RENEWAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 51.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.61, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 23.31 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.31 } ], "minimum": 23.31, "maximum": 25.9 } ] }, { "description": "DRAPE THYROID T 100 X72 X124 MED", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 26.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 12.64, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 11.97 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.97 } ], "minimum": 11.97, "maximum": 13.3 } ] }, { "description": "NEEDLE HUBER POWERLOCK MCKESSON", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20.35, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.67, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9.1575 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.175 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.1575 } ], "minimum": 9.1575, "maximum": 10.175 } ] }, { "description": "CELL SAVER-RESERVOIR", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 264, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 125.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 118.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 132 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 118.8 } ], "minimum": 118.8, "maximum": 132 } ] }, { "description": "ESOPHAGEALL PROBE PED 12FR", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.528 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.92 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.528 } ], "minimum": 3.528, "maximum": 3.92 } ] }, { "description": "3 INCH ACE STERILE MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.99 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.99 } ], "minimum": 0.99, "maximum": 1.1 } ] }, { "description": "CUFF TOURNIQUET 18 IN X 3 IN RENEWAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 51.81, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.61, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 23.3145 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.905 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.3145 } ], "minimum": 23.3145, "maximum": 25.905 } ] }, { "description": "SUCTION TIP FRAZIER 12 FR DISPOSABL MEDL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.18, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.96 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.96 } ], "minimum": 3.96, "maximum": 4.4 } ] }, { "description": "DRESSING XEROFORM STR 5X9 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.35, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.5075 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.675 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.5075 } ], "minimum": 1.5075, "maximum": 1.675 } ] }, { "description": "NEEDLE TOUHY 20 GAUGE WITH WINGS MCK", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15.43, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 7.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.9435 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.715 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.9435 } ], "minimum": 6.9435, "maximum": 7.715 } ] }, { "description": "CPT TOTAL JOINT PACK AMS MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 279.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 132.66, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 125.676 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 139.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 125.676 } ], "minimum": 125.676, "maximum": 139.64 } ] }, { "description": "MAJOR ORTHO GLOVE CHARGE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 85, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 40.38, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 38.25 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 42.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 38.25 } ], "minimum": 38.25, "maximum": 42.5 } ] }, { "description": "COBAN BANDAGE TAN STERILE 6 X5YD MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.97, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.652 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.28 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.652 } ], "minimum": 5.652, "maximum": 6.28 } ] }, { "description": "CPT BASIC CUSTOM PACK MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 145.04, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 68.89, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 65.268 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 72.52 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 65.268 } ], "minimum": 65.268, "maximum": 72.52 } ] }, { "description": "LMA 2.5 PEDIATRIC AMBU", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 44.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 21, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 19.89 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.89 } ], "minimum": 19.89, "maximum": 22.1 } ] }, { "description": "SMALL DERMABOND PEN MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 36, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.2 } ], "minimum": 16.2, "maximum": 18 } ] }, { "description": "HEAD HALTER CHIN STRAP MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.6 } ], "minimum": 3.6, "maximum": 4 } ] }, { "description": "LMA 2.0 PEDIATRIC AMBU", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 33.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.06, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.21 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.21 } ], "minimum": 15.21, "maximum": 16.9 } ] }, { "description": "SUTURE VICRYL CT-1 2-0 18 POP OFF", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.86, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.92 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.92 } ], "minimum": 16.92, "maximum": 18.8 } ] }, { "description": "6 INCH ACE NONSTERILE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.47, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.34 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.34 } ], "minimum": 2.34, "maximum": 2.6 } ] }, { "description": "DECANTER II MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.65, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.21, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.0925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.325 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.0925 } ], "minimum": 2.0925, "maximum": 2.325 } ] }, { "description": "BLADE ELECTRODE 6.5 EXTENDED MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20.24, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.61, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9.108 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.12 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.108 } ], "minimum": 9.108, "maximum": 10.12 } ] }, { "description": "SUTURE MONCRYL 4-0 PS-2 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17.76, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 8.44, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7.992 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.88 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.992 } ], "minimum": 7.992, "maximum": 8.88 } ] }, { "description": "SODIUM CHL IV SOL 0.90% 250ML MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.528 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.92 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.528 } ], "minimum": 3.528, "maximum": 3.92 } ] }, { "description": "CAST PADDING UNDERCAST 4", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.402 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.78 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.402 } ], "minimum": 3.402, "maximum": 3.78 } ] }, { "description": "BONE COLLECTOR ANSPACH DEPUY SYNTHES", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 712, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 338.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 320.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 356 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 320.4 } ], "minimum": 320.4, "maximum": 356 } ] }, { "description": "NEEDLE NERVE STIM 20GX4' I FLOW", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 54.24, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 25.76, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 24.408 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 27.12 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 24.408 } ], "minimum": 24.408, "maximum": 27.12 } ] }, { "description": "NEEDLE SPINAL 18G X 3 1/2", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.556 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.84 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.556 } ], "minimum": 2.556, "maximum": 2.84 } ] }, { "description": "MOOG TUBING PUMP SET LG VOL INFUSION", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 34.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.444 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.444 } ], "minimum": 15.444, "maximum": 17.16 } ] }, { "description": "RAYTEC SPONGE 4 X4 16-42446", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.58, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.448 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.448 } ], "minimum": 2.448, "maximum": 2.72 } ] }, { "description": "SPONGE NEURO STR 1/2 X3 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.24, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.29, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.958 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.62 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.958 } ], "minimum": 5.958, "maximum": 6.62 } ] }, { "description": "TEGADERM DRESSING 6 X 8 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.76, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.142 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.38 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.142 } ], "minimum": 2.142, "maximum": 2.38 } ] }, { "description": "BONE MILL DISPOSABLE MEDTRONIC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1231, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 584.73, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 553.95 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 615.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 553.95 } ], "minimum": 553.95, "maximum": 615.5 } ] }, { "description": "DRAPE LOWER EXTREMITY MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 67.43, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 32.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 30.3435 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 33.715 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 30.3435 } ], "minimum": 30.3435, "maximum": 33.715 } ] }, { "description": "CPT PODIATRY PACK AMS MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 151.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 71.93, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 68.148 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 75.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 68.148 } ], "minimum": 68.148, "maximum": 75.72 } ] }, { "description": "ECHOBRIGHT NEEDLE NERVE STIM 22X2", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 46.36, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 22.02, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 20.862 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.18 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.862 } ], "minimum": 20.862, "maximum": 23.18 } ] }, { "description": "DRESSING MEDI-PAK SMALL TELFA STR 3''X4", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 0.29, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.14, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.1305 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.145 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.1305 } ], "minimum": 0.1305, "maximum": 0.145 } ] }, { "description": "4 INCH ACE NONSTERILE MK", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.88, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.32, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.196 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.44 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.196 } ], "minimum": 2.196, "maximum": 2.44 } ] }, { "description": "TUBE ENDOTRACH 7.5 CUFF W/STYLETTE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.178 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.42 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.178 } ], "minimum": 2.178, "maximum": 2.42 } ] }, { "description": "SUTURE PDS 1 TP-1", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.64, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.838 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.82 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.838 } ], "minimum": 8.838, "maximum": 9.82 } ] }, { "description": "BLADE SAW SAG TOTALS CHIASSON ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 136.64, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 64.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 61.488 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 68.32 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 61.488 } ], "minimum": 61.488, "maximum": 68.32 } ] }, { "description": "ENDO BUTTON KIT ORCA STERILE SINGLE USE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35.7, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.96, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.065 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.85 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.065 } ], "minimum": 16.065, "maximum": 17.85 } ] }, { "description": "CPT ARTHROSCOPY PK MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 206.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 98, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 92.844 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 103.16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 92.844 } ], "minimum": 92.844, "maximum": 103.16 } ] }, { "description": "CHIASSON FLEX MASTER ACE XTRA LONG MED", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 10.93, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.35 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.35 } ], "minimum": 10.35, "maximum": 11.5 } ] }, { "description": "HYDRA AIR WATER CAP BOSTON SCIENTIFIC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 43.25, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 20.54, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 19.4625 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.625 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.4625 } ], "minimum": 19.4625, "maximum": 21.625 } ] }, { "description": "ASEPTO SYR IRR BULB 60ML MEDL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.64, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.25, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.188 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.32 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.188 } ], "minimum": 1.188, "maximum": 1.32 } ] }, { "description": "WATER BOTTLE TUBING SYSTEM ENDO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 34.27, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.4215 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.135 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.4215 } ], "minimum": 15.4215, "maximum": 17.135 } ] }, { "description": "DISTRACTION PIN 12MM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 120, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 57, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 54 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 60 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 54 } ], "minimum": 54, "maximum": 60 } ] }, { "description": "SUTURE VICRYL 2-0 SH 27", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.91, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.2095 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.455 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.2095 } ], "minimum": 2.2095, "maximum": 2.455 } ] }, { "description": "HYDRA WATER JET ENDO CONNECTOR", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.49, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.08, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.9205 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.245 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.9205 } ], "minimum": 2.9205, "maximum": 3.245 } ] }, { "description": "SPONGE NEURO 3/4 X 3/4 STR", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 22.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 10.64, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.08 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.08 } ], "minimum": 10.08, "maximum": 11.2 } ] }, { "description": "BLADE RECIP SAW ORTHO ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 167.52, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 79.57, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 75.384 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 83.76 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 75.384 } ], "minimum": 75.384, "maximum": 83.76 } ] }, { "description": "PUMP TUBING ARTHROSCOPY ARTHREX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 192, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 91.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 86.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 96 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 86.4 } ], "minimum": 86.4, "maximum": 96 } ] }, { "description": "SUTURE 2 VICRYL TP-1", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.32, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.04 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.04 } ], "minimum": 5.04, "maximum": 5.6 } ] }, { "description": "HOLMIUM LASER FIBER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 400, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 190, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 180 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 200 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 180 } ], "minimum": 180, "maximum": 200 } ] }, { "description": "BLADE SURGICAL C/S STR #11 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.57, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.54 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.54 } ], "minimum": 0.54, "maximum": 0.6 } ] }, { "description": "BANDAGE CNFRM STRCH 4 STR LF MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.63, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.594 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.66 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.594 } ], "minimum": 0.594, "maximum": 0.66 } ] }, { "description": "PACK UNIVERSAL MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 59.54, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 28.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 26.793 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.77 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.793 } ], "minimum": 26.793, "maximum": 29.77 } ] }, { "description": "BAG LEG DISP MED 19OZ MCK", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.71, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.51 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.51 } ], "minimum": 3.51, "maximum": 3.9 } ] }, { "description": "SUTURE MONOCRYL 3-0 PS-2", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.04, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.04, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.568 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.52 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.568 } ], "minimum": 8.568, "maximum": 9.52 } ] }, { "description": "LAP SPONGE XRAY 18 X18 STR MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.16 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.16 } ], "minimum": 2.16, "maximum": 2.4 } ] }, { "description": "GLIDESCOPE SIZE 3 DISPOSABLE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 91.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 43.32, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 41.04 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 45.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 41.04 } ], "minimum": 41.04, "maximum": 45.6 } ] }, { "description": "PULSAVAC IRRIGATOR ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 133.76, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 63.54, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 60.192 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 66.88 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 60.192 } ], "minimum": 60.192, "maximum": 66.88 } ] }, { "description": "SUTURE VICRYL 0 UR-6", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.42, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.24 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.24 } ], "minimum": 3.24, "maximum": 3.6 } ] }, { "description": "CPT CATH LAB MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 143.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 68.19, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 64.602 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 71.78 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 64.602 } ], "minimum": 64.602, "maximum": 71.78 } ] }, { "description": "FOLEY STABILIZATION DEVICE MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.4 } ], "minimum": 5.4, "maximum": 6 } ] }, { "description": "GEL ULTRAS AQUASONIC 20GM BLUE MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.22, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.106 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.34 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.106 } ], "minimum": 2.106, "maximum": 2.34 } ] }, { "description": "DRAPE IOBAN LARGE 6651EZ MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.78, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.848 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.848 } ], "minimum": 16.848, "maximum": 18.72 } ] }, { "description": "STRATAFIX MONOCRYL 4-0 SPIRAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 64.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 30.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 28.944 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 32.16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 28.944 } ], "minimum": 28.944, "maximum": 32.16 } ] }, { "description": "BANDAGE CNFRM STRCH 3 STR LF MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 0.97, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.46, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.4365 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.485 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.4365 } ], "minimum": 0.4365, "maximum": 0.485 } ] }, { "description": "BAND BAG 40X40 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.63, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.62, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.4335 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.815 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.4335 } ], "minimum": 3.4335, "maximum": 3.815 } ] }, { "description": "CATHETER IV JELCO 20GX1 W/OUT SAFETY", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.82, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.728 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.92 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.728 } ], "minimum": 1.728, "maximum": 1.92 } ] }, { "description": "JP BULB 100CC MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.03, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 10.94, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.3635 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.515 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.3635 } ], "minimum": 10.3635, "maximum": 11.515 } ] }, { "description": "LMA-SUPREME SZ 5 AMBU", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 33.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.06, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.21 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.21 } ], "minimum": 15.21, "maximum": 16.9 } ] }, { "description": "CPT 360 NEURO PACK MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 483.24, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 229.54, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 217.458 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 241.62 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 217.458 } ], "minimum": 217.458, "maximum": 241.62 } ] }, { "description": "DRAPE SURG INSTR POUCH MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.89 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.89 } ], "minimum": 1.89, "maximum": 2.1 } ] }, { "description": "CEMENT MIXING SYSTEM ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 401.16, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 190.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 180.522 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 200.58 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 180.522 } ], "minimum": 180.522, "maximum": 200.58 } ] }, { "description": "STONE BASKET TIPLESS GLOBAL LASER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 720, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 342, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 324 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 360 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 324 } ], "minimum": 324, "maximum": 360 } ] }, { "description": "TEFLON BOVIE TIP EDGE 2.5 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.676 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.676 } ], "minimum": 8.676, "maximum": 9.64 } ] }, { "description": "IMPERVIOUS SPLIT DRAPE MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 24.64, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 11.088 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.32 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.088 } ], "minimum": 11.088, "maximum": 12.32 } ] }, { "description": "CORD BI-POLAR 12' MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.04, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.77, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.518 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.02 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.518 } ], "minimum": 4.518, "maximum": 5.02 } ] }, { "description": "THOMPSON LOR 7 CC LUER LOCK TIP MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.32, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.04 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.04 } ], "minimum": 5.04, "maximum": 5.6 } ] }, { "description": "SUTURE VICRYL 4-0 PS-2", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 7.45, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7.056 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.84 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.056 } ], "minimum": 7.056, "maximum": 7.84 } ] }, { "description": "NEEDLE EPIDURAL BRAUN 18G 3 1/2 TOUHY", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12.87, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.11, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.7915 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.435 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.7915 } ], "minimum": 5.7915, "maximum": 6.435 } ] }, { "description": "SUTURE ETHILON PSLX 2-0", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.37, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.03 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.7 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.03 } ], "minimum": 6.03, "maximum": 6.7 } ] }, { "description": "GREEN LIGHT LASER FIBER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7400, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3515, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3330 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3700 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3330 } ], "minimum": 3330, "maximum": 3700 } ] }, { "description": "SUTURE SILK BLK 2-0 SH 30", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.926 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.14 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.926 } ], "minimum": 1.926, "maximum": 2.14 } ] }, { "description": "ADULT SPO2 SENSOR MAXA COVIDIEN", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 40.99, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 19.47, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 18.4455 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.495 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.4455 } ], "minimum": 18.4455, "maximum": 20.495 } ] }, { "description": "SUTURE ETHILON 4-0 PS-2 18", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.37, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.03 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.7 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.03 } ], "minimum": 6.03, "maximum": 6.7 } ] }, { "description": "SUTURE PDS 2-0 CT-2", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9.04, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.29, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.068 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.52 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.068 } ], "minimum": 4.068, "maximum": 4.52 } ] }, { "description": "BOTOX NEEDLE SHORT", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 298, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 141.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 134.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 149 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 134.1 } ], "minimum": 134.1, "maximum": 149 } ] }, { "description": "SOD CHL SOLIV 0.45% 1000ML MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 44.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 19.98 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.98 } ], "minimum": 19.98, "maximum": 22.2 } ] }, { "description": "CANNULA 7X75MM RIGID ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 224, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 106.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 100.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 112 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 100.8 } ], "minimum": 100.8, "maximum": 112 } ] }, { "description": "TUBING CONN STR 3/16 X6' MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.52, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.684 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.76 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.684 } ], "minimum": 0.684, "maximum": 0.76 } ] }, { "description": "BOVIE SCRATCH PAD CLEANER MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.26, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.567 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.63 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.567 } ], "minimum": 0.567, "maximum": 0.63 } ] }, { "description": "DRAPE C-ARM MINI ORTHOSCAN", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 55, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.13, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 24.75 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 27.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 24.75 } ], "minimum": 24.75, "maximum": 27.5 } ] }, { "description": "DRAIN HUBLESS RND PERF 10FR", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 62.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 29.77, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 28.206 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 31.34 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 28.206 } ], "minimum": 28.206, "maximum": 31.34 } ] }, { "description": "KERLIX BANDAGE 4.5 PERFM STR", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.59, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.71, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.6155 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.795 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.6155 } ], "minimum": 1.6155, "maximum": 1.795 } ] }, { "description": "DIAL-A-FLO EXTENSION SET", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.994 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.66 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.994 } ], "minimum": 5.994, "maximum": 6.66 } ] }, { "description": "SPONGE GZE 2 X2 8PLY STR LF PERFM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 0.21, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.0945 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.105 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.0945 } ], "minimum": 0.0945, "maximum": 0.105 } ] }, { "description": "SUTURE SILK 3-0 30 TIES", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.08, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.79, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.536 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.04 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.536 } ], "minimum": 4.536, "maximum": 5.04 } ] }, { "description": "DRAGONFLY EMG ELECTRODE FOR ET TUBE NEUR", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 627.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 297.92, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 282.24 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 313.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 282.24 } ], "minimum": 282.24, "maximum": 313.6 } ] }, { "description": "TRAY PREP 4461A MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14.36, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.82, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.462 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.18 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.462 } ], "minimum": 6.462, "maximum": 7.18 } ] }, { "description": "LIGACLIP MED LONG MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 173.47, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 78.0615 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 86.735 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 78.0615 } ], "minimum": 78.0615, "maximum": 86.735 } ] }, { "description": "EXOFIN SKIN CLOSURE FUSION SYSTEM MEDLIN", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 432.76, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 205.56, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 194.742 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 216.38 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 194.742 } ], "minimum": 194.742, "maximum": 216.38 } ] }, { "description": "COVER MAYO STAND REINF", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.11, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.998 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.22 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.998 } ], "minimum": 1.998, "maximum": 2.22 } ] }, { "description": "WILSON FRAME KIT MIZUHOSI", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 151, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 71.73, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 67.95 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 75.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 67.95 } ], "minimum": 67.95, "maximum": 75.5 } ] }, { "description": "SUTURE VICRYL 3-0 RAPIDE PS-1 VR935", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.21, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.62 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.62 } ], "minimum": 10.62, "maximum": 11.8 } ] }, { "description": "GLIDESCOPE SIZE 4 DISPOSABLE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 91.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 43.32, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 41.04 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 45.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 41.04 } ], "minimum": 41.04, "maximum": 45.6 } ] }, { "description": "MICROSCOPE DRAPE PENTERO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 47.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 45 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 45 } ], "minimum": 45, "maximum": 50 } ] }, { "description": "DRAPE HIP W/POCKET MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 71.9, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 34.15, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 32.355 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 35.95 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 32.355 } ], "minimum": 32.355, "maximum": 35.95 } ] }, { "description": "STYLET INTUBATION 14FR", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.12, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.43, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.304 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.56 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.304 } ], "minimum": 2.304, "maximum": 2.56 } ] }, { "description": "SUTURE PDS 3-0 SH VIOLET", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.12, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.906 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.34 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.906 } ], "minimum": 3.906, "maximum": 4.34 } ] }, { "description": "BOUGIE ENDOTRACHEAL TUBE PORTEX 15FR", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 31.64, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 15.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 14.238 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.82 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.238 } ], "minimum": 14.238, "maximum": 15.82 } ] }, { "description": "MANIFOLD KIT", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 118.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 56.43, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 53.46 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 59.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 53.46 } ], "minimum": 53.46, "maximum": 59.4 } ] }, { "description": "ESOPHTEMP ADULT 18FR CARD", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.65, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.456 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.84 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.456 } ], "minimum": 3.456, "maximum": 3.84 } ] }, { "description": "SUTURE SILK 0 SH", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.36, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.07, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.962 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.18 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.962 } ], "minimum": 1.962, "maximum": 2.18 } ] }, { "description": "TRIGGER SPRAY BOTTLE STERILE 32 OZ", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.15, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.65, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.7175 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.575 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.7175 } ], "minimum": 16.7175, "maximum": 18.575 } ] }, { "description": "4.0 ARTHREX BARREL BURR", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 176, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 83.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 79.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 88 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 79.2 } ], "minimum": 79.2, "maximum": 88 } ] }, { "description": "COUNTER NEEDLE MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.56, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.476 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.476 } ], "minimum": 1.476, "maximum": 1.64 } ] }, { "description": "SHOULDER SUSPENSION SLEEVE ARTHR", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 201.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 95.76, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 90.72 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 100.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 90.72 } ], "minimum": 90.72, "maximum": 100.8 } ] }, { "description": "SUTURE QUILL 2 CTX 36X36 RA-1065Q MEDLIN", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 87.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 41.46, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 39.276 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 43.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 39.276 } ], "minimum": 39.276, "maximum": 43.64 } ] }, { "description": "SUTURE ETHILON 2-0 FS", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.14, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.97 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.97 } ], "minimum": 2.97, "maximum": 3.3 } ] }, { "description": "SPONGE NEURO 1/2 X 1/2 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.61, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.31 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.31 } ], "minimum": 5.31, "maximum": 5.9 } ] }, { "description": "BLADE SURGICAL C/S STR #10 CARDINAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.57, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.54 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.54 } ], "minimum": 0.54, "maximum": 0.6 } ] }, { "description": "STOCKINETTE IMP PERFM 9 X 48 MED", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.48, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.066 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.74 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.066 } ], "minimum": 6.066, "maximum": 6.74 } ] }, { "description": "CATHETER IV JELCO 18GX1 1/4 W/OUT SAFET", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.77, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.628 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.92 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.628 } ], "minimum": 2.628, "maximum": 2.92 } ] }, { "description": "SOD CHL IVSOL 0.90% 50ML MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.53, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.348 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.348 } ], "minimum": 3.348, "maximum": 3.72 } ] }, { "description": "DRAPE CARDIO XL 87 X 135", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 30.55, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 14.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 13.7475 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.275 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.7475 } ], "minimum": 13.7475, "maximum": 15.275 } ] }, { "description": "3 INCH ACE NONSTERILE MCK", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.26 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.26 } ], "minimum": 1.26, "maximum": 1.4 } ] }, { "description": "CATHETER IV JELCO 24GX3/4 W/O SAFETY", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.24, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.01, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.908 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.12 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.908 } ], "minimum": 1.908, "maximum": 2.12 } ] }, { "description": "CPT ENT CUSTOM PACK MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 80.97, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 38.46, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 36.4365 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 40.485 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 36.4365 } ], "minimum": 36.4365, "maximum": 40.485 } ] }, { "description": "BLADE AVERAGE MEDIUM STRYKER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 217.08, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 103.11, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 97.686 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 108.54 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 97.686 } ], "minimum": 97.686, "maximum": 108.54 } ] }, { "description": "NEEDLE SPINAL STR 25GX3 1/2", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.844 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.844 } ], "minimum": 2.844, "maximum": 3.16 } ] }, { "description": "BLOOD SET Y-TYPE TUBING CARESITE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 45.29, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 20.3805 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.645 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.3805 } ], "minimum": 20.3805, "maximum": 22.645 } ] }, { "description": "AIRWAY NASO PHARY 7.0MM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21.16, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 10.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9.522 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.58 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.522 } ], "minimum": 9.522, "maximum": 10.58 } ] }, { "description": "CATHETER IV JELCO 16GX1 1/4", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.42, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.24 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.24 } ], "minimum": 3.24, "maximum": 3.6 } ] }, { "description": "SYRINGE CATH TIP 50CC MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.26 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.26 } ], "minimum": 1.26, "maximum": 1.4 } ] }, { "description": "90 DEGREE LIGHTWAVE ABLATOR", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 316.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 150.48, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 142.56 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 158.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 142.56 } ], "minimum": 142.56, "maximum": 158.4 } ] }, { "description": "MAYFIELD SKULL PIN PRO MED", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 126.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 60, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 56.844 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 63.16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 56.844 } ], "minimum": 56.844, "maximum": 63.16 } ] }, { "description": "FOLEY CATHETER COUDE 20FR 5CC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 43.41, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 20.62, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 19.5345 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.705 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.5345 } ], "minimum": 19.5345, "maximum": 21.705 } ] }, { "description": "COVER TABLE BACK", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.59, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.7655 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.295 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.7655 } ], "minimum": 4.7655, "maximum": 5.295 } ] }, { "description": "DISSECTOR 5.5MM ARTHREX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 176, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 83.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 79.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 88 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 79.2 } ], "minimum": 79.2, "maximum": 88 } ] }, { "description": "SUTURE SILK 0 30 TIES", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.16 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.16 } ], "minimum": 2.16, "maximum": 2.4 } ] }, { "description": "CUFF DISP TOURNIQUET 24 X4 RENEWAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 42.36, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 20.12, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 19.062 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.18 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.062 } ], "minimum": 19.062, "maximum": 21.18 } ] }, { "description": "VALVE ULTRASITE 415110", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.178 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.42 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.178 } ], "minimum": 2.178, "maximum": 2.42 } ] }, { "description": "IRRISEPT JET LAVAGE 450ML MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 280, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 133, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 126 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 140 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 126 } ], "minimum": 126, "maximum": 140 } ] }, { "description": "FIBERWIRE #5 ARTHREX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 168, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 79.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 75.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 84 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 75.6 } ], "minimum": 75.6, "maximum": 84 } ] }, { "description": "ANGIO NEEDLE 18 GAUGE MERIT MEDICAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.18, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.96 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.96 } ], "minimum": 3.96, "maximum": 4.4 } ] }, { "description": "TIGER EXPRESS Y NEEDLE STRYKER SPINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1000, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 475, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 450 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 450 } ], "minimum": 450, "maximum": 500 } ] }, { "description": "SUTURE CHROMIC 3-0 SH 27", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9.88, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.69, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.446 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.94 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.446 } ], "minimum": 4.446, "maximum": 4.94 } ] }, { "description": "SUTURE PLAIN GUT 5-0 PC-1", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 22.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 10.58, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.026 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.14 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.026 } ], "minimum": 10.026, "maximum": 11.14 } ] }, { "description": "SUTURE PROLENE BV-1 5-0", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 107.15, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 50.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 48.2175 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 53.575 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 48.2175 } ], "minimum": 48.2175, "maximum": 53.575 } ] }, { "description": "DONUT CUSHION 5X9 ROUND MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.87, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.0915 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.435 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.0915 } ], "minimum": 3.0915, "maximum": 3.435 } ] }, { "description": "SUTURE PDS 4-0 PS-2 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.34, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.19, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.703 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.67 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.703 } ], "minimum": 8.703, "maximum": 9.67 } ] }, { "description": "LARGE BONE BLADE 1.14MM SAGITTAL BROYLES", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 104.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 49.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 47.106 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 52.34 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 47.106 } ], "minimum": 47.106, "maximum": 52.34 } ] }, { "description": "DOMANGUE SYRINGE LOR EPILOR 7ML MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.38, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.094 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.66 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.094 } ], "minimum": 5.094, "maximum": 5.66 } ] }, { "description": "SUTURE 3-0 ETHILON PS-1", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14.21, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.3945 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.105 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.3945 } ], "minimum": 6.3945, "maximum": 7.105 } ] }, { "description": "SUTURE VICRYL 5-0 PS-2", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.15, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.25, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.9175 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.575 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.9175 } ], "minimum": 5.9175, "maximum": 6.575 } ] }, { "description": "BLADE MEDIUM NARROW STRYKER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 151.76, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 72.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 68.292 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 75.88 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 68.292 } ], "minimum": 68.292, "maximum": 75.88 } ] }, { "description": "GLASS SYRINGE 10ML LL METAL TIP", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 43.48, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 20.65, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 19.566 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.74 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.566 } ], "minimum": 19.566, "maximum": 21.74 } ] }, { "description": "DISSECTOR SHAVER BLADE 5.0 MM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 176, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 83.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 79.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 88 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 79.2 } ], "minimum": 79.2, "maximum": 88 } ] }, { "description": "CUFF DISP TOURNIQUET 42 X 3", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 51.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.61, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 23.31 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.31 } ], "minimum": 23.31, "maximum": 25.9 } ] }, { "description": "NEEDLE RF 20G 150MM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 66, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 31.35, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 29.7 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 33 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.7 } ], "minimum": 29.7, "maximum": 33 } ] }, { "description": "BANDAGE CNFRM STRCH 2 STR LF", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.16, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.972 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.08 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.972 } ], "minimum": 0.972, "maximum": 1.08 } ] }, { "description": "SUTURE VICRYL 2-0 CT-2 POP OFF", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 36.37, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.3665 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.185 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.3665 } ], "minimum": 16.3665, "maximum": 18.185 } ] }, { "description": "BIOPSY HOT RADICAL JAW 2.8 BOS SCI", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 81.91, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 38.91, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 36.8595 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 40.955 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 36.8595 } ], "minimum": 36.8595, "maximum": 40.955 } ] }, { "description": "DRILL BIT 4.5MM ZIMMER (SPD)", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 324.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 154.19, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 146.07 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 162.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 146.07 } ], "minimum": 146.07, "maximum": 162.3 } ] }, { "description": "DRAPE PLASTIC U-DRAPE MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.71, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.56, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.2695 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.855 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.2695 } ], "minimum": 5.2695, "maximum": 5.855 } ] }, { "description": "DRESSING TELFA STR 2X3 1'S CARDINAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 0.12, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.06, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.054 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.06 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.054 } ], "minimum": 0.054, "maximum": 0.06 } ] }, { "description": "LOOP VESSEL MAXI CARD BLU STR MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.42, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.24 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.24 } ], "minimum": 3.24, "maximum": 3.6 } ] }, { "description": "DRAIN HUBLESS FLT FULL PERF", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 38.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 18.32, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 17.352 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.28 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.352 } ], "minimum": 17.352, "maximum": 19.28 } ] }, { "description": "BANDAGE CNFRM STRCH 6 x 80 STR LF", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.82, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.728 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.92 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.728 } ], "minimum": 1.728, "maximum": 1.92 } ] }, { "description": "HIP ABDUCTION PILLOW DJO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 71.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 34.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 32.256 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 35.84 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 32.256 } ], "minimum": 32.256, "maximum": 35.84 } ] }, { "description": "4.0 ARTHREX SHAVER BLADE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 176, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 83.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 79.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 88 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 79.2 } ], "minimum": 79.2, "maximum": 88 } ] }, { "description": "SUTURE VICRYL 1 CT-1 POP OFF", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 44.16, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 20.98, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 19.872 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.08 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.872 } ], "minimum": 19.872, "maximum": 22.08 } ] }, { "description": "AUTOTRANSFUSION SET MBA MEDICAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 180.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 171 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 190 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 171 } ], "minimum": 171, "maximum": 190 } ] }, { "description": "CATHETER FOLEY 20FR 5CC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.44, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.102 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.78 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.102 } ], "minimum": 6.102, "maximum": 6.78 } ] }, { "description": "6FR M COAT GLIDESHEATH", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 272, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 129.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 122.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 136 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 122.4 } ], "minimum": 122.4, "maximum": 136 } ] }, { "description": "PERFORMANCE SERIES SAG BLADE STYRKER G", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 252.88, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 120.12, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 113.796 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 126.44 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 113.796 } ], "minimum": 113.796, "maximum": 126.44 } ] }, { "description": "DRAPE STERI LARGE 1050 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.56, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.32 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.32 } ], "minimum": 4.32, "maximum": 4.8 } ] }, { "description": "SUTURE SILK 2-0 30 TIES", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.95, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.744 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.744 } ], "minimum": 3.744, "maximum": 4.16 } ] }, { "description": "SUTURE 4-0 PROLENE PS-2", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.24, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.14, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.658 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.62 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.658 } ], "minimum": 8.658, "maximum": 9.62 } ] }, { "description": "GLYCINE IRR 3000ML R8406", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 64.36, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 30.57, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 28.962 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 32.18 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 28.962 } ], "minimum": 28.962, "maximum": 32.18 } ] }, { "description": "TUBE SALEM SUMP 16FR CARDINAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.8 } ], "minimum": 1.8, "maximum": 2 } ] }, { "description": "CHLORAPREP 1.5 ML IV SITE CARDINAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.22, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.152 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.28 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.152 } ], "minimum": 1.152, "maximum": 1.28 } ] }, { "description": "STERI-DRAPE WITH POUCH", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12.24, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.81, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.508 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.12 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.508 } ], "minimum": 5.508, "maximum": 6.12 } ] }, { "description": "SUTURE PROLENE BV-1 6-0 DR HARROD", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 59.04, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 28.04, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 26.568 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.52 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.568 } ], "minimum": 26.568, "maximum": 29.52 } ] }, { "description": "PATH DRIVE SHAFT CANNULA MICROPORT ORTHO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 400, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 190, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 180 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 200 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 180 } ], "minimum": 180, "maximum": 200 } ] }, { "description": "FLEXTIP BIPOLAR RF ELECTRODE ARTHREX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4400, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2090, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1980 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2200 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1980 } ], "minimum": 1980, "maximum": 2200 } ] }, { "description": "PUMP SET BLOOD Y TYPE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 28.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 12.978 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.42 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.978 } ], "minimum": 12.978, "maximum": 14.42 } ] }, { "description": "SUTURE PDS 5-0 P-3 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.34, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.19, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.703 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.67 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.703 } ], "minimum": 8.703, "maximum": 9.67 } ] }, { "description": "SUTURE SILK 0 CT-1 P/O MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 29.77, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 14.14, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 13.3965 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.885 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.3965 } ], "minimum": 13.3965, "maximum": 14.885 } ] }, { "description": "ALVARADO DISPOSABLE LINER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 90, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 40.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 45 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 40.5 } ], "minimum": 40.5, "maximum": 45 } ] }, { "description": "CATH TRAY URETH 15FR 772415 MCK", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.08, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.76 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.76 } ], "minimum": 5.76, "maximum": 6.4 } ] }, { "description": "BONE MARROW BIOPSY NEEDLE JAMISHIDI 11G", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 81.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 38.76, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 36.72 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 40.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 36.72 } ], "minimum": 36.72, "maximum": 40.8 } ] }, { "description": "DRAPE RADIAL FEMORAL CARDINAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 42, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 19.95, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 18.9 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 21 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.9 } ], "minimum": 18.9, "maximum": 21 } ] }, { "description": "CIV-FLEX TRANSDUCER COVER CIVCO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35.17, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.71, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.8265 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.585 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.8265 } ], "minimum": 15.8265, "maximum": 17.585 } ] }, { "description": "FLEXCIL LINE 20 NAVILYST MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 10.37, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9.828 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.92 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.828 } ], "minimum": 9.828, "maximum": 10.92 } ] }, { "description": "SUTURE PROLENE 3-0 PS-1", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18.36, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 8.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.262 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.18 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.262 } ], "minimum": 8.262, "maximum": 9.18 } ] }, { "description": "SYRINGE LL 60CC MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.69, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.2105 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.345 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.2105 } ], "minimum": 1.2105, "maximum": 1.345 } ] }, { "description": "ORAL RAE ETT CUFF 7.0MM CARDINAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.22, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.73 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.7 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.73 } ], "minimum": 8.73, "maximum": 9.7 } ] }, { "description": "LIGACLIP LARGE XLONG", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 175.39, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 83.31, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 78.9255 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 87.695 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 78.9255 } ], "minimum": 78.9255, "maximum": 87.695 } ] }, { "description": "CATHETER 10FR RED RBR STR MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.27, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.206 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.34 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.206 } ], "minimum": 1.206, "maximum": 1.34 } ] }, { "description": "SUTURE MONOCRYL 3-0 SH MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.15 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.15 } ], "minimum": 3.15, "maximum": 3.5 } ] }, { "description": "COVERDERM DRESSING 4X6 MCK", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.92, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.81, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.664 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.96 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.664 } ], "minimum": 2.664, "maximum": 2.96 } ] }, { "description": "COBLATOR PROCISE MAX ARTHROCARE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1243.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.71, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 559.62 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 621.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 559.62 } ], "minimum": 559.62, "maximum": 621.8 } ] }, { "description": "QUIKCLOT RADIAL TELEFLEX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 126.1, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 59.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 56.745 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 63.05 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 56.745 } ], "minimum": 56.745, "maximum": 63.05 } ] }, { "description": "ENDOCAVITY NEEDLE GUIDE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 68.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 32.62, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 30.906 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 34.34 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 30.906 } ], "minimum": 30.906, "maximum": 34.34 } ] }, { "description": "ANTIFOG/FRED ENDO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.45, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.06, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.9025 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.225 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.9025 } ], "minimum": 2.9025, "maximum": 3.225 } ] }, { "description": "SOL STERILE WATER IRR 500ML", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.36, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.076 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.076 } ], "minimum": 5.076, "maximum": 5.64 } ] }, { "description": "SUTURE 4-0 CHROMIC RB-1", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.64, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.788 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.32 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.788 } ], "minimum": 4.788, "maximum": 5.32 } ] }, { "description": "SUTURE MONOCRYL RB-1 4-0", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.46, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.276 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.276 } ], "minimum": 3.276, "maximum": 3.64 } ] }, { "description": "CATHETER FR 4 EXPO 6FR BOSTON SCI", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.84 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.84 } ], "minimum": 15.84, "maximum": 17.6 } ] }, { "description": "SUTURE PROLENE 3-0 PS-2", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.25, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.04, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.4625 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.625 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.4625 } ], "minimum": 10.4625, "maximum": 11.625 } ] }, { "description": "SUTURE PDS 2-0 CT-1 ETHICON ENDO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.36, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.97, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.762 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.18 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.762 } ], "minimum": 3.762, "maximum": 4.18 } ] }, { "description": "STRATAFIX 30 X 30CM 3-0", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 94.12, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 44.71, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 42.354 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 47.06 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 42.354 } ], "minimum": 42.354, "maximum": 47.06 } ] }, { "description": "LITE Y WIRE STRYKER SPINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 800, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 380, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 360 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 400 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 360 } ], "minimum": 360, "maximum": 400 } ] }, { "description": "CANNULA 7X7 ARTHREX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 105, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 49.88, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 47.25 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 52.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 47.25 } ], "minimum": 47.25, "maximum": 52.5 } ] }, { "description": "SUTURE 4-0 VICRYL SH MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.08, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.41, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.286 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.54 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.286 } ], "minimum": 2.286, "maximum": 2.54 } ] }, { "description": "CATHETER SCTN GRAD 14FR MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.36, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.65, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.612 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.68 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.612 } ], "minimum": 0.612, "maximum": 0.68 } ] }, { "description": "PORTAL DILATION NEEDLE ARTHREX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 273, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 129.68, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 122.85 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 136.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 122.85 } ], "minimum": 122.85, "maximum": 136.5 } ] }, { "description": "STRYKER BLADE LONG MED", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 151.76, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 72.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 68.292 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 75.88 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 68.292 } ], "minimum": 68.292, "maximum": 75.88 } ] }, { "description": "SUTURE PLAIN GUT 4-0 SC-1 KEITH", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.07, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.78, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.5315 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.035 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.5315 } ], "minimum": 4.5315, "maximum": 5.035 } ] }, { "description": "MAX CORE BIOPSY INSTRUMENT", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 141.59, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 67.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 63.7155 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 70.795 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 63.7155 } ], "minimum": 63.7155, "maximum": 70.795 } ] }, { "description": "ORTHO BAR DRAPE 100 X 60 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15.18, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 7.21, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.831 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.59 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.831 } ], "minimum": 6.831, "maximum": 7.59 } ] }, { "description": "HEAD / CHIN STRAP RESTRAINT BEACH CHAIR", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.71, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9.198 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.22 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.198 } ], "minimum": 9.198, "maximum": 10.22 } ] }, { "description": "GUIDE PIN 2.5 ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 749.08, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 355.81, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 337.086 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 374.54 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 337.086 } ], "minimum": 337.086, "maximum": 374.54 } ] }, { "description": "NEEDLE 20G 6 EPIDURAL TOUHY", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 27.72, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.17, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 12.474 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.86 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.474 } ], "minimum": 12.474, "maximum": 13.86 } ] }, { "description": "BLADEMYRINGOTOMY SPEAR INTEGRA", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 33.42, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 15.87, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.039 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.71 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.039 } ], "minimum": 15.039, "maximum": 16.71 } ] }, { "description": "SNARE POLYPECTOMY SENSATION 27MM BOS SCI", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 79.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 37.91, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 35.91 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 39.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 35.91 } ], "minimum": 35.91, "maximum": 39.9 } ] }, { "description": "DRILL BIT 2.0MM ROUND NEURO BURR H", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 609.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 289.48, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 274.248 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 304.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 274.248 } ], "minimum": 274.248, "maximum": 304.72 } ] }, { "description": "APOLLO RF 90 MULTIPORT ARTHREX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 760, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 361, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 342 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 380 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 342 } ], "minimum": 342, "maximum": 380 } ] }, { "description": "ROBOTICS SURGICAL DRAPE STERILE MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 88.72, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.14, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 39.924 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 44.36 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 39.924 } ], "minimum": 39.924, "maximum": 44.36 } ] }, { "description": "BODY LOTION REMEDY 2 OZ MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.27, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.206 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.34 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.206 } ], "minimum": 1.206, "maximum": 1.34 } ] }, { "description": "DRILL BIT 3.2MM ACETABULAR ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 374.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 177.92, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 168.552 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 187.28 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 168.552 } ], "minimum": 168.552, "maximum": 187.28 } ] }, { "description": "DRESSING CHANGE TRAY CTRL LINE STR LF", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 29.36, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.95, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 13.212 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.68 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.212 } ], "minimum": 13.212, "maximum": 14.68 } ] }, { "description": "HELIOCOIDAL RASP MEDIUM STRYKER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 581.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.11, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 261.576 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 290.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 261.576 } ], "minimum": 261.576, "maximum": 290.64 } ] }, { "description": "CATHETER PLUG SMALL MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.74, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.68, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.483 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.87 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.483 } ], "minimum": 3.483, "maximum": 3.87 } ] }, { "description": "PATTIE 1 X 3 NEURO SPONGE MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 7.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.876 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.876 } ], "minimum": 6.876, "maximum": 7.64 } ] }, { "description": "TIGER RADIAL CATH 5FR 4.0 TERUMO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 180, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 85.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 81 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 90 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 81 } ], "minimum": 81, "maximum": 90 } ] }, { "description": "CUTTING LOOP 24F PROSURGE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 280, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 133, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 126 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 140 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 126 } ], "minimum": 126, "maximum": 140 } ] }, { "description": "CRYSTAL CANNULA ARTHREX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 105, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 49.88, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 47.25 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 52.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 47.25 } ], "minimum": 47.25, "maximum": 52.5 } ] }, { "description": "BLADE ELECTRODE 4.0 NON COATED MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.39, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.21, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.7255 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.695 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.7255 } ], "minimum": 8.7255, "maximum": 9.695 } ] }, { "description": "DRILL GUIDE BIT 2.5 2021 ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 799.04, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.54, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 359.568 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 399.52 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 359.568 } ], "minimum": 359.568, "maximum": 399.52 } ] }, { "description": "CATHETER IV JELCO 22GX1 W/OUT SAFETY", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.42, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.24 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.24 } ], "minimum": 3.24, "maximum": 3.6 } ] }, { "description": "CONNECTOR 5 IN 1 STR CARDINAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.67, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.79, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.7515 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.835 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.7515 } ], "minimum": 0.7515, "maximum": 0.835 } ] }, { "description": "2 INCH ACE NONSTERILE MCK", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.12, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.48, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.404 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.56 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.404 } ], "minimum": 1.404, "maximum": 1.56 } ] }, { "description": "LIGACLIP SMALL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 172.7, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 77.715 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 86.35 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 77.715 } ], "minimum": 77.715, "maximum": 86.35 } ] }, { "description": "BLADE 15C MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.99 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.99 } ], "minimum": 0.99, "maximum": 1.1 } ] }, { "description": "DRAPE SHOULDER W/ POUCH MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 103.03, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.94, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 46.3635 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 51.515 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 46.3635 } ], "minimum": 46.3635, "maximum": 51.515 } ] }, { "description": "SUTURE PROLENE 8-0 BV130-5 DR WARNER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 63.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 30.31, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 28.71 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 31.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 28.71 } ], "minimum": 28.71, "maximum": 31.9 } ] }, { "description": "NEURO CROSS CUT CARBIDE BURR STRYKER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 609.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 289.48, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 274.248 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 304.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 274.248 } ], "minimum": 274.248, "maximum": 304.72 } ] }, { "description": "CATHETER COUNCILL LTX 16FR 5CC MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 49.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 23.66, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 22.41 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 24.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.41 } ], "minimum": 22.41, "maximum": 24.9 } ] }, { "description": "STRAIGHT SHOT XPS IRRIGATOR TUBING", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 125.04, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 59.39, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 56.268 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 62.52 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 56.268 } ], "minimum": 56.268, "maximum": 62.52 } ] }, { "description": "SUTURE 0 NUROLON MO-6", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 40.66, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 19.31, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 18.297 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.33 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.297 } ], "minimum": 18.297, "maximum": 20.33 } ] }, { "description": "NEEDLE MAYO 1/2 CIRCLE TROCAR POINTE MED", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.64, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.838 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.82 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.838 } ], "minimum": 8.838, "maximum": 9.82 } ] }, { "description": "TORPEDO SHAVER ARTHREX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 404, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 191.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 181.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 202 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 181.8 } ], "minimum": 181.8, "maximum": 202 } ] }, { "description": "REUTER BIVALVE FLUOR. INTRANASAL SPLINT", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 178.04, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 84.57, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 80.118 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 89.02 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 80.118 } ], "minimum": 80.118, "maximum": 89.02 } ] }, { "description": "DISSECTOR ENDO BLNT TIP", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 49.66, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 23.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 22.347 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 24.83 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.347 } ], "minimum": 22.347, "maximum": 24.83 } ] }, { "description": "SALEM SUMP 12FR CARDINAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.1, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.745 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.05 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.745 } ], "minimum": 2.745, "maximum": 3.05 } ] }, { "description": "TRACKER INSTRUMENT MEDTRONIC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 634, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 301.15, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 285.3 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 317 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 285.3 } ], "minimum": 285.3, "maximum": 317 } ] }, { "description": "TRACKER PATIENT MEDTRONIC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 780.04, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 370.52, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 351.018 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 390.02 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 351.018 } ], "minimum": 351.018, "maximum": 390.02 } ] }, { "description": "SUTURE VICRYL 0 UNDYED CT-1 36IN", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.47, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.34 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.34 } ], "minimum": 2.34, "maximum": 2.6 } ] }, { "description": "SUTURE VICRYL 0 CT-2", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.51, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.9295 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.255 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.9295 } ], "minimum": 2.9295, "maximum": 3.255 } ] }, { "description": "TIP BOVIE RIGHT ANGLE MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 93.88, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 44.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 42.246 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 46.94 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 42.246 } ], "minimum": 42.246, "maximum": 46.94 } ] }, { "description": "SURGICEL 4 X8 ETHICON ENDO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 163, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 77.43, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 73.35 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 81.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 73.35 } ], "minimum": 73.35, "maximum": 81.5 } ] }, { "description": "SUTURE VICRYL 3-0 RAPIDE PS-2 VR497", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21.74, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 10.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9.783 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.87 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.783 } ], "minimum": 9.783, "maximum": 10.87 } ] }, { "description": "BLADE SHORT NARROW STRYKER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 151.76, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 72.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 68.292 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 75.88 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 68.292 } ], "minimum": 68.292, "maximum": 75.88 } ] }, { "description": "LIGHT HANDLE CATH LAB ONLY CARD", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.09, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.47, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.3905 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.545 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.3905 } ], "minimum": 1.3905, "maximum": 1.545 } ] }, { "description": "SUTURE MONOCRYL 3-0 PS-1", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20.88, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.92, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9.396 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.44 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.396 } ], "minimum": 9.396, "maximum": 10.44 } ] }, { "description": "CATHETER FL4 EXPO 6FR BOSTON SCI", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.84 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.84 } ], "minimum": 15.84, "maximum": 17.6 } ] }, { "description": "FLUID WARMER TUBING/CARTRIDGE RANGER MED", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 34.64, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.45, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.588 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.32 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.588 } ], "minimum": 15.588, "maximum": 17.32 } ] }, { "description": "WOUND VAC 10 X 30 PICO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1172, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 556.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 527.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 586 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 527.4 } ], "minimum": 527.4, "maximum": 586 } ] }, { "description": "BLADE SAW PRECISION OFFSET 25MM STRYKER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 151.76, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 72.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 68.292 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 75.88 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 68.292 } ], "minimum": 68.292, "maximum": 75.88 } ] }, { "description": "BLADE SAW PRECISION 25MM DR. DILEO BLADE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 151.76, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 72.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 68.292 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 75.88 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 68.292 } ], "minimum": 68.292, "maximum": 75.88 } ] }, { "description": "FIBERTAPE SUTURE ARTHREX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 441, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 209.48, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 198.45 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 220.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 198.45 } ], "minimum": 198.45, "maximum": 220.5 } ] }, { "description": "OMNICURVE 11x20MM FRACTURE KIT", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9200, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4370, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4140 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4600 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4140 } ], "minimum": 4140, "maximum": 4600 } ] }, { "description": "NEEDLE SPINAL 25GX2.5 QUINCKE MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.17, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.006 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.34 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.006 } ], "minimum": 3.006, "maximum": 3.34 } ] }, { "description": "TRIGGER FLEX DART PROBE ELLIQUENCE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3800, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1805, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1710 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1900 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1710 } ], "minimum": 1710, "maximum": 1900 } ] }, { "description": "INTRODUCER ELLIQUENCE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 200, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 95, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 90 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 100 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 90 } ], "minimum": 90, "maximum": 100 } ] }, { "description": "CUSHION PRONE VIEW", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 47.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 45 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 45 } ], "minimum": 45, "maximum": 50 } ] }, { "description": "LIGACLIP MED SHORT", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 173.47, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 78.0615 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 86.735 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 78.0615 } ], "minimum": 78.0615, "maximum": 86.735 } ] }, { "description": "NEEDLE WHITACRE 25G X 3 1/2IN MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18.9, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 8.98, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.505 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.45 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.505 } ], "minimum": 8.505, "maximum": 9.45 } ] }, { "description": "SUTURE PROLENE 3-0 SH", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 24.72, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.74, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 11.124 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.36 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.124 } ], "minimum": 11.124, "maximum": 12.36 } ] }, { "description": "SUTURE VICRYL 3-0 PS-1 27", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14.43, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.85, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.4935 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.215 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.4935 } ], "minimum": 6.4935, "maximum": 7.215 } ] }, { "description": "SUREFIRE SCORPION NEEDLE SUTUREMITT", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 588, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 279.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 264.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 294 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 264.6 } ], "minimum": 264.6, "maximum": 294 } ] }, { "description": "ORAL RAE ETT CUFF 4.0", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 27.95, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 12.5775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.975 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.5775 } ], "minimum": 12.5775, "maximum": 13.975 } ] }, { "description": "BIOPSY LARGE 2.8 WITH NEEDLE BOS SCI", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 53.76, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 25.54, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 24.192 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.88 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 24.192 } ], "minimum": 24.192, "maximum": 26.88 } ] }, { "description": "SUTURE PROLENE 5-0 RB-1 DBL ARM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20.04, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.52, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9.018 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.02 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.018 } ], "minimum": 9.018, "maximum": 10.02 } ] }, { "description": "NEEDLE 1/2 CIRCLE REF # 216704 ASPEN SU", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.64, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.838 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.82 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.838 } ], "minimum": 8.838, "maximum": 9.82 } ] }, { "description": "PREFILLED HUMIDIFIER 500ML CARDINAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.12, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.004 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.56 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.004 } ], "minimum": 5.004, "maximum": 5.56 } ] }, { "description": "TUBING Y ARTHREX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 39.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 37.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 42 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 37.8 } ], "minimum": 37.8, "maximum": 42 } ] }, { "description": "FLAT TIP NO BULB SUCTION YANKAUER CARDIN", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.37, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.13, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.0665 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.185 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.0665 } ], "minimum": 1.0665, "maximum": 1.185 } ] }, { "description": "TRIPLEDAM YELLOW CANNULA ARTHREX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 134.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 63.84, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 60.48 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 67.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 60.48 } ], "minimum": 60.48, "maximum": 67.2 } ] }, { "description": "AVAFLEX CURVED NEEDLE STRYKER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1881, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 893.48, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 846.45 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 940.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 846.45 } ], "minimum": 846.45, "maximum": 940.5 } ] }, { "description": "ANTERIOR ISOLATION HIP DRAPE 6619", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 81.12, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 38.53, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 36.504 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 40.56 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 36.504 } ], "minimum": 36.504, "maximum": 40.56 } ] }, { "description": "CATHETER ANGIOCATH 14G X 5-1/4", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 86.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 41.25, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 39.078 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 43.42 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 39.078 } ], "minimum": 39.078, "maximum": 43.42 } ] }, { "description": "PUPIL DILATORS SIGHTPATH MEDICAL CO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 652.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 310.08, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 293.76 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 326.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 293.76 } ], "minimum": 293.76, "maximum": 326.4 } ] }, { "description": "DRILL BIT 2.8MM SOLID CORE MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 400, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 190, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 180 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 200 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 180 } ], "minimum": 180, "maximum": 200 } ] }, { "description": "CEMENT MIXING BOWL 2021 ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 299.64, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 134.838 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 149.82 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 134.838 } ], "minimum": 134.838, "maximum": 149.82 } ] }, { "description": "DRAPE BILATERAL EXTREMITY CARDINAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 30.65, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 14.56, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 13.7925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.325 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.7925 } ], "minimum": 13.7925, "maximum": 15.325 } ] }, { "description": "TOURNIQUET CUFF 30 X4", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 46.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.95, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 20.79 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.79 } ], "minimum": 20.79, "maximum": 23.1 } ] }, { "description": "BLADE ROTATABLE FUSION TRICUT 13CM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1201.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 570.87, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 540.828 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 600.92 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 540.828 } ], "minimum": 540.828, "maximum": 600.92 } ] }, { "description": "SNARE POLYPECTOMY SENSATION 13MM BOS SCI", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 79.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 37.91, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 35.91 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 39.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 35.91 } ], "minimum": 35.91, "maximum": 39.9 } ] }, { "description": "ADHESIVE PAD ENT MEDTRONIC NAVIGATION", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.69, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9.18 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.18 } ], "minimum": 9.18, "maximum": 10.2 } ] }, { "description": "SUTURE PDS #1 CTX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12.27, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.83, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.5215 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.135 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.5215 } ], "minimum": 5.5215, "maximum": 6.135 } ] }, { "description": "ENDOSCRUB ENDOSHEATHS 0 DEGREE MEDT", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 252.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 119.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 113.49 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 126.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 113.49 } ], "minimum": 113.49, "maximum": 126.1 } ] }, { "description": "BALLOON SINUPLASTY SYSTEM W/GUIDES ACCLA", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7800, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3705, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3510 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3900 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3510 } ], "minimum": 3510, "maximum": 3900 } ] }, { "description": "BABY LAP SPONGE XRAY 4 X18 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.85, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.35, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.2825 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.425 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.2825 } ], "minimum": 1.2825, "maximum": 1.425 } ] }, { "description": "IVAS ACCESS CANNULA STRYKER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 260, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 117 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 130 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 117 } ], "minimum": 117, "maximum": 130 } ] }, { "description": "DRILL BIT 2.5 MEDARTIS L91MM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 468.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 222.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 210.87 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 234.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 210.87 } ], "minimum": 210.87, "maximum": 234.3 } ] }, { "description": "SUTURE PASSER QUATTRO ZIMMERBIOM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 700, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 332.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 315 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 350 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 315 } ], "minimum": 315, "maximum": 350 } ] }, { "description": "DRILL BIT 2.0MM SOLID CORE MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 400, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 190, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 180 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 200 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 180 } ], "minimum": 180, "maximum": 200 } ] }, { "description": "CATHETER FOLEY SILICONE 16FR MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.31, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.976 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.976 } ], "minimum": 5.976, "maximum": 6.64 } ] }, { "description": "SYR EAR BULB 25-402", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.33, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.06, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.9485 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.165 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.9485 } ], "minimum": 1.9485, "maximum": 2.165 } ] }, { "description": "CATHETER LTX 3WAY 30CC 22FR CARDINAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.88, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.246 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.94 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.246 } ], "minimum": 6.246, "maximum": 6.94 } ] }, { "description": "DRESSING VASELINE GAUZE CARDINAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 0.66, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.31, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.297 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.33 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.297 } ], "minimum": 0.297, "maximum": 0.33 } ] }, { "description": "CATHETER COUDE 14FR 5CC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 48.35, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 22.97, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 21.7575 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 24.175 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.7575 } ], "minimum": 21.7575, "maximum": 24.175 } ] }, { "description": "SUCTION TIP FRAZIER 8 FR DISPOSABL MED", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.99, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.78 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.78 } ], "minimum": 3.78, "maximum": 4.2 } ] }, { "description": "PINNACLE SHEALTH 6FR TERUMO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 43.48, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 20.65, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 19.566 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.74 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.566 } ], "minimum": 19.566, "maximum": 21.74 } ] }, { "description": "CATHETER FOLEY ALL SIL 14FR 5CC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.36, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.35, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.012 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.68 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.012 } ], "minimum": 6.012, "maximum": 6.68 } ] }, { "description": "OMNICURVE 10x20MM FRACTURE KIT", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9200, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4370, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4140 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4600 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4140 } ], "minimum": 4140, "maximum": 4600 } ] }, { "description": "TAPER POINT PDSII VIOLET CT-2 SUTURE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.95, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.25, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.0275 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.475 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.0275 } ], "minimum": 4.0275, "maximum": 4.475 } ] }, { "description": "CATHETER COUDE 16FR 5CC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 43, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 20.43, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 19.35 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.35 } ], "minimum": 19.35, "maximum": 21.5 } ] }, { "description": "DRILL BIT 4.3 ORTHOFIX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1073.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 509.96, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 483.12 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 536.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 483.12 } ], "minimum": 483.12, "maximum": 536.8 } ] }, { "description": "DRILL BIT 3.5MM ENOVIS", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 860, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 408.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 387 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 430 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 387 } ], "minimum": 387, "maximum": 430 } ] }, { "description": "DRILL BIT 2.7MM ENOVIS", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 860, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 408.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 387 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 430 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 387 } ], "minimum": 387, "maximum": 430 } ] }, { "description": "DRILL BIT 2.0 SHORT 2021 ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 324.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 154.19, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 146.07 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 162.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 146.07 } ], "minimum": 146.07, "maximum": 162.3 } ] }, { "description": "DRILL BIT 4.3 ORTHOFIX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1100, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 522.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 495 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 550 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 495 } ], "minimum": 495, "maximum": 550 } ] }, { "description": "SUTURE PROLENE 2-0 DBL ARMED 36 SH", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 24.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.944 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.944 } ], "minimum": 10.944, "maximum": 12.16 } ] }, { "description": "SUTURE VICRYL 1 CT-1 36INCH", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.07, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.36, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.1815 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.535 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.1815 } ], "minimum": 3.1815, "maximum": 3.535 } ] }, { "description": "AIRWAY NASO PHARY 6.0MM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20.24, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.61, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9.108 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.12 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.108 } ], "minimum": 9.108, "maximum": 10.12 } ] }, { "description": "CATHETER SCTN GRAD 10FR CARDINAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.83, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.87, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.8235 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.915 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.8235 } ], "minimum": 0.8235, "maximum": 0.915 } ] }, { "description": "CATHETER SCTN GRAD 12FR", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.73, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.2285 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.365 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.2285 } ], "minimum": 1.2285, "maximum": 1.365 } ] }, { "description": "SUTURE SILK RB-1 4/0", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.81, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.0645 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.405 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.0645 } ], "minimum": 3.0645, "maximum": 3.405 } ] }, { "description": "ORAL RAE ETT CUFF 5.0MM CARDINAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 28.88, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 12.996 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.44 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.996 } ], "minimum": 12.996, "maximum": 14.44 } ] }, { "description": "TUBE SALEM SUMP 14FR", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.03, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.34, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.1635 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.515 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.1635 } ], "minimum": 3.1635, "maximum": 3.515 } ] }, { "description": "ELECTRODE NEEDLE TIP 1", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.22, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.106 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.34 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.106 } ], "minimum": 2.106, "maximum": 2.34 } ] }, { "description": "SUTURE SILK 3-0 TIES 18", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.83, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.77, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.6235 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.915 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.6235 } ], "minimum": 2.6235, "maximum": 2.915 } ] }, { "description": "SUTURE 2-0 SILK 18 TIE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.23, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.96, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.8035 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.115 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.8035 } ], "minimum": 2.8035, "maximum": 3.115 } ] }, { "description": "SUTURE VICRYL 3/0 RB-1", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.55, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.64, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.4975 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.775 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.4975 } ], "minimum": 2.4975, "maximum": 2.775 } ] }, { "description": "ABD BINDER 46-62 (9 3-PANEL)", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 24.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.944 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.944 } ], "minimum": 10.944, "maximum": 12.16 } ] }, { "description": "FOLEY CATHETER 3-WAY 5CC 20FR CARDINAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.04, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.04, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.568 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.52 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.568 } ], "minimum": 8.568, "maximum": 9.52 } ] }, { "description": "BLANKET UNDERBODY CARDINAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 95.41, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 45.32, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 42.9345 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 47.705 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 42.9345 } ], "minimum": 42.9345, "maximum": 47.705 } ] }, { "description": "LUMBAR DRAIN INSERTION NEEDLE/CATHETER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1148, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 545.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 516.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 574 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 516.6 } ], "minimum": 516.6, "maximum": 574 } ] }, { "description": "PURPLE MIDAS REX DRILL BIT", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 561.96, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 266.93, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 252.882 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 280.98 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 252.882 } ], "minimum": 252.882, "maximum": 280.98 } ] }, { "description": "PINNACLE SHEALTH 7FR TERUMO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 43.48, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 20.65, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 19.566 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.74 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.566 } ], "minimum": 19.566, "maximum": 21.74 } ] }, { "description": "SUTURE PDS 1 CT-1 ETHICON ENDO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.86, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.887 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.43 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.887 } ], "minimum": 4.887, "maximum": 5.43 } ] }, { "description": "SUTURE NYLON AU-8 DA", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 122.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 58.14, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 55.08 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 61.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 55.08 } ], "minimum": 55.08, "maximum": 61.2 } ] }, { "description": "BOTOX NEEDLE LONG ADJUST TIP", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 368, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 174.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 165.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 184 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 165.6 } ], "minimum": 165.6, "maximum": 184 } ] }, { "description": "CATHETER IV SURFLO 18GX2 W/OUT SAFETY", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9.47, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.2615 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.735 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.2615 } ], "minimum": 4.2615, "maximum": 4.735 } ] }, { "description": "CHECKPOINT GUARDIAN NERVE STIMULATOR", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2784, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1322.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1252.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1392 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1252.8 } ], "minimum": 1252.8, "maximum": 1392 } ] }, { "description": "SUTURE 3-0 ETHILON PSL-1", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16.7, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 7.93, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7.515 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.35 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.515 } ], "minimum": 7.515, "maximum": 8.35 } ] }, { "description": "VERTEBRAL 10G BODY CEMENT CANNULA", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 240, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 114, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 108 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 120 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 108 } ], "minimum": 108, "maximum": 120 } ] }, { "description": "SKIN MARKER BLACK WRITESITE PLUS STERILE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.35, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.12, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.0575 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.175 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.0575 } ], "minimum": 1.0575, "maximum": 1.175 } ] }, { "description": "TUNNELING TOOL BOSTON SCIENTIFIC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.8 } ], "minimum": 1.8, "maximum": 2 } ] }, { "description": "HOLMIUM LASER FIBER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 513, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 486 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 540 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 486 } ], "minimum": 486, "maximum": 540 } ] }, { "description": "GUIDE PIN", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 196, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 93.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 88.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 98 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 88.2 } ], "minimum": 88.2, "maximum": 98 } ] }, { "description": "CANNULA 7X85MM RIGID 2021 ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 180, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 85.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 81 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 90 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 81 } ], "minimum": 81, "maximum": 90 } ] }, { "description": "SUPERPATH SCREW DRILL MICROPORT ORTHO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 200, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 95, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 90 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 100 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 90 } ], "minimum": 90, "maximum": 100 } ] }, { "description": "IMPLANT ALIF PROB INNOVASIS", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1260, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 598.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 567 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 630 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 567 } ], "minimum": 567, "maximum": 630 } ] }, { "description": "IVAS 10G 15MM IVAS ELITE FRACTURE KIT ST", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9383.12, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4456.98, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4222.404 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4691.56 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4222.404 } ], "minimum": 4222.404, "maximum": 4691.56 } ] }, { "description": "TRAY SPINAL PENCAN 25G ML", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 59.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 28.29, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 26.802 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.78 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.802 } ], "minimum": 26.802, "maximum": 29.78 } ] }, { "description": "SUTURE VICRYL 1 CTX 36 UNDYED", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.96, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.31, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.132 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.48 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.132 } ], "minimum": 3.132, "maximum": 3.48 } ] }, { "description": "ARTERIAL ABG KIT BLOOD GAS FOR RESP", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.58, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.494 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.66 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.494 } ], "minimum": 1.494, "maximum": 1.66 } ] }, { "description": "ORAL RAE ETT CUFF 6.5MM MCKESSON", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 27.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 12.348 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.348 } ], "minimum": 12.348, "maximum": 13.72 } ] }, { "description": "REMOVER SKIN STAPLES DISP CARDINAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.48, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.816 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.24 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.816 } ], "minimum": 3.816, "maximum": 4.24 } ] }, { "description": "SUTURE PROLENE 0 CT-1", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.54, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.01, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.743 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.27 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.743 } ], "minimum": 4.743, "maximum": 5.27 } ] }, { "description": "HEWSON RETRIEVER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 761.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 361.76, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 342.72 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 380.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 342.72 } ], "minimum": 342.72, "maximum": 380.8 } ] }, { "description": "ORTHO 2.1 CROSS CUT TPXDRILL STRYKER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 25.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 12.08, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 11.448 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.448 } ], "minimum": 11.448, "maximum": 12.72 } ] }, { "description": "SUTURE ETHILON #2 LR", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9.11, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.0995 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.555 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.0995 } ], "minimum": 4.0995, "maximum": 4.555 } ] }, { "description": "LIGASURE MAX HANDPIECE LF1212A", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1270.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 603.54, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 571.77 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 635.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 571.77 } ], "minimum": 571.77, "maximum": 635.3 } ] }, { "description": "CATHETER COUNCILL TIP 18FR 5CC RED RUBBE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 49.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 23.66, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 22.41 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 24.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.41 } ], "minimum": 22.41, "maximum": 24.9 } ] }, { "description": "SWAN-GANZ 5 FR CATHETER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1121.68, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 532.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 504.756 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 560.84 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 504.756 } ], "minimum": 504.756, "maximum": 560.84 } ] }, { "description": "LUMBAR DRAINAGE CANNISTER MEDTRONIC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1108, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 526.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 498.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 554 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 498.6 } ], "minimum": 498.6, "maximum": 554 } ] }, { "description": "NGAGE NITINOL STONE BASKET", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 919.52, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 436.77, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 413.784 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 459.76 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 413.784 } ], "minimum": 413.784, "maximum": 459.76 } ] }, { "description": "URETERAL DILATOR AQ COOK", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 106, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 50.35, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 47.7 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 53 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 47.7 } ], "minimum": 47.7, "maximum": 53 } ] }, { "description": "RESOLUTION 360 ENDOCLIP BOSTON SCIENTIFI", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1066.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 506.73, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 480.06 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 533.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 480.06 } ], "minimum": 480.06, "maximum": 533.4 } ] }, { "description": "QUADCUT BLADE4.3MM STRAIGHT MEDTRONIC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1386.52, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 658.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 623.934 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 693.26 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 623.934 } ], "minimum": 623.934, "maximum": 693.26 } ] }, { "description": "HANA PATIENT CARE KIT OSI", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 136.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 64.98, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 61.56 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 68.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 61.56 } ], "minimum": 61.56, "maximum": 68.4 } ] }, { "description": "SUTURE 5-0 PROLENE C-1", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 67.3, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 31.97, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 30.285 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 33.65 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 30.285 } ], "minimum": 30.285, "maximum": 33.65 } ] }, { "description": "FLOPPY SUCTION TUBING CONMED DR KOGA", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.58, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.13, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.961 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.29 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.961 } ], "minimum": 2.961, "maximum": 3.29 } ] }, { "description": "OMNICURVE 10G 20MM EXTRA LEVEL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5060, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2403.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2277 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2530 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2277 } ], "minimum": 2277, "maximum": 2530 } ] }, { "description": "SUTURE 3-0 SURGILON DR BOWLIN", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.67, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.49, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.1515 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.835 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.1515 } ], "minimum": 6.1515, "maximum": 6.835 } ] }, { "description": "DRILL BIT 2.0 SHORT ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 318.24, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 151.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 143.208 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 159.12 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 143.208 } ], "minimum": 143.208, "maximum": 159.12 } ] }, { "description": "CONTRAST INJECTION LINE 48 HPCIL MEDLI", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.63, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.52, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.2335 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.815 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.2335 } ], "minimum": 5.2335, "maximum": 5.815 } ] }, { "description": "VISCOELASTIC SIGHTPATH", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 244.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 116.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 110.16 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 122.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 110.16 } ], "minimum": 110.16, "maximum": 122.4 } ] }, { "description": "PATIENT TRIAL BOX KIT BOS SCI", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.8 } ], "minimum": 1.8, "maximum": 2 } ] }, { "description": "DRILL BIT 2.0 2021 ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 824, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 391.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 370.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 412 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 370.8 } ], "minimum": 370.8, "maximum": 412 } ] }, { "description": "EXTERNAL PULSE GENERATOR 2 PORT SJM ABBO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 400, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 190, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 180 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 200 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 180 } ], "minimum": 180, "maximum": 200 } ] }, { "description": "GUIDE PIN PARTIAL THD TIP 1.6MM ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 349.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 166.04, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 157.302 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 174.78 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 157.302 } ], "minimum": 157.302, "maximum": 174.78 } ] }, { "description": "QC DRILL CANNULATED 2.7 ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1997.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 948.84, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 898.902 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 998.78 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 898.902 } ], "minimum": 898.902, "maximum": 998.78 } ] }, { "description": "GUIDEWIRE 0.9 X 150MM SMOOTH MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 80, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 38, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 36 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 40 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 36 } ], "minimum": 36, "maximum": 40 } ] }, { "description": "GUIDEPIN MIS 3.0 150MM MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 160, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 76, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 72 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 80 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 72 } ], "minimum": 72, "maximum": 80 } ] }, { "description": "STAPLE 2.8MM DRILL PACK OSSIO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1380, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 655.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 621 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 690 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 621 } ], "minimum": 621, "maximum": 690 } ] }, { "description": "DRILL BIT 2.0 / QC 150MM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4088, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1941.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1839.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2044 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1839.6 } ], "minimum": 1839.6, "maximum": 2044 } ] }, { "description": "FREEHAND DRILL 4.3MM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 809.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.56, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 364.32 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 404.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 364.32 } ], "minimum": 364.32, "maximum": 404.8 } ] }, { "description": "FIBERWIRE 2-0", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 92.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 43.89, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 41.58 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 46.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 41.58 } ], "minimum": 41.58, "maximum": 46.2 } ] }, { "description": "DRAPE LAP TRANSVERSE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.54, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.18, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.593 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.77 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.593 } ], "minimum": 10.593, "maximum": 11.77 } ] }, { "description": "CLOSURE STRI-STP 1/4X4", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.33, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.06, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.9485 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.165 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.9485 } ], "minimum": 1.9485, "maximum": 2.165 } ] }, { "description": "TIP INSULATED 6.5 BOVIE VALLEYLAB MEDLI", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.96, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.38, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.782 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.98 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.782 } ], "minimum": 10.782, "maximum": 11.98 } ] }, { "description": "LOOP VESSEL MINI CARD RED STR", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.23, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.43, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.2535 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.615 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.2535 } ], "minimum": 3.2535, "maximum": 3.615 } ] }, { "description": "WIPE INSTRUMENT 83MM X 83MM MEROCEL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.36, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.312 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.68 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.312 } ], "minimum": 3.312, "maximum": 3.68 } ] }, { "description": "STATLOCK PICC LINE FOAM BARD MEDICAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16.64, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 7.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7.488 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.32 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.488 } ], "minimum": 7.488, "maximum": 8.32 } ] }, { "description": "ANTI-REFLUX VALVE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 27.96, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 12.582 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.98 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.582 } ], "minimum": 12.582, "maximum": 13.98 } ] }, { "description": "PACKING 1/4 X 5 YARDS", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.49, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.202 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.78 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.202 } ], "minimum": 5.202, "maximum": 5.78 } ] }, { "description": "SUTURE VICRYL 2-0 CT-2", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.65, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.9925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.325 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.9925 } ], "minimum": 2.9925, "maximum": 3.325 } ] }, { "description": "CROSS CUT FISSURE CARBIDE BURR STRYKER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 25.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 12.08, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 11.448 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.448 } ], "minimum": 11.448, "maximum": 12.72 } ] }, { "description": "BURR EGG STRYKER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 233.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 110.77, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 104.94 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 116.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 104.94 } ], "minimum": 104.94, "maximum": 116.6 } ] }, { "description": "DOYLE II NASAL SEPTAL SPLINT MED", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 260.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.88, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 117.36 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 130.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 117.36 } ], "minimum": 117.36, "maximum": 130.4 } ] }, { "description": "CORNEAL PROTECTOR BAUSCH AND LOMB", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.01, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.11 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.11 } ], "minimum": 16.11, "maximum": 17.9 } ] }, { "description": "SUBDERMAL ELECTRODES 2 CHAN NIM MED", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 404.88, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 192.32, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 182.196 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 202.44 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 182.196 } ], "minimum": 182.196, "maximum": 202.44 } ] }, { "description": "INCREMENTING PROBE NIM MEDTRONIC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 789.12, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 374.83, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 355.104 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 394.56 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 355.104 } ], "minimum": 355.104, "maximum": 394.56 } ] }, { "description": "ORAL RAE ETT CUFFED TUBE 8.0 CARDINAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 28.89, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 13.0005 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.445 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.0005 } ], "minimum": 13.0005, "maximum": 14.445 } ] }, { "description": "SUTURE NYLON CLEAR 5/0 P-3", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18.95, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.5275 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.475 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.5275 } ], "minimum": 8.5275, "maximum": 9.475 } ] }, { "description": "SUTURE MONOCRYL 5-0 RB-1", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.88, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.74, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.546 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.94 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.546 } ], "minimum": 3.546, "maximum": 3.94 } ] }, { "description": "SUTURE MONOCRYL 4-0 SH", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.88, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.22, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.996 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.44 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.996 } ], "minimum": 3.996, "maximum": 4.44 } ] }, { "description": "CATHETER EXPO PIGTAIL 145", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.84 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.84 } ], "minimum": 15.84, "maximum": 17.6 } ] }, { "description": "TIGER RADIAL CATH 6FR 4.0 TERUMO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 180, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 85.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 81 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 90 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 81 } ], "minimum": 81, "maximum": 90 } ] }, { "description": "CATHETER EXPO WRP 6FR BOSTON SCIENTIFIC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.84 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.84 } ], "minimum": 15.84, "maximum": 17.6 } ] }, { "description": "GREEN MIDAS REX DRILL BIT", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 514.08, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 244.19, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 231.336 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 257.04 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 231.336 } ], "minimum": 231.336, "maximum": 257.04 } ] }, { "description": "COLORADO BOVIE TIP STRYKER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 480, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 228, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 216 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 240 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 216 } ], "minimum": 216, "maximum": 240 } ] }, { "description": "INDEFLATOR PLUS MERIT MEDICAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 115.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 54.78, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 51.894 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 57.66 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 51.894 } ], "minimum": 51.894, "maximum": 57.66 } ] }, { "description": "STONE BASKET TIPLESS", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 804.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 382.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 361.944 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 402.16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 361.944 } ], "minimum": 361.944, "maximum": 402.16 } ] }, { "description": "CATHETER FOLEY BARDIA 2-WAY 18FR SILICON", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.72, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.77, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.674 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.86 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.674 } ], "minimum": 1.674, "maximum": 1.86 } ] }, { "description": "VERRATTA FFR/IFR WIRE VOLCANO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2600, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1235, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1170 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1300 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1170 } ], "minimum": 1170, "maximum": 1300 } ] }, { "description": "CONTINUOUS NERVE BLCK SET 18GA X 100MM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 158.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.34, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 71.37 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 79.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 71.37 } ], "minimum": 71.37, "maximum": 79.3 } ] }, { "description": "BLADE 2.9 CURVED SINUS BLADE MEDTRONIC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1027.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 487.92, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 462.24 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 513.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 462.24 } ], "minimum": 462.24, "maximum": 513.6 } ] }, { "description": "NEURO KOGA 3.0 ROUND DIAMOND STRYKE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 565.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 268.64, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 254.502 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 282.78 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 254.502 } ], "minimum": 254.502, "maximum": 282.78 } ] }, { "description": "DRAPE HAND STERILE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 28.82, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.69, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 12.969 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.41 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.969 } ], "minimum": 12.969, "maximum": 14.41 } ] }, { "description": "ABD BINDER 46-62 (12 4-PANEL)", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 36.98, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.57, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.641 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.49 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.641 } ], "minimum": 16.641, "maximum": 18.49 } ] }, { "description": "NEEDLE SPINAL 18GAUGE FOR DISC FX SYSTE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 199.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.91, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 89.91 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 99.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 89.91 } ], "minimum": 89.91, "maximum": 99.9 } ] }, { "description": "BEAM DRILL BIT VILEX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 580, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 275.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 261 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 290 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 261 } ], "minimum": 261, "maximum": 290 } ] }, { "description": "PASSING ELEVATOR BOSTON SCIENTIFIC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 160, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 76, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 72 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 80 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 72 } ], "minimum": 72, "maximum": 80 } ] }, { "description": "DRILL BIT NCB ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 474.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 225.36, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 213.498 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 237.22 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 213.498 } ], "minimum": 213.498, "maximum": 237.22 } ] }, { "description": "DRILL BIT 2.9 ANCHOR ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 812, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 385.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 365.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 406 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 365.4 } ], "minimum": 365.4, "maximum": 406 } ] }, { "description": "EZ PASS 45 DEGREE UP ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 680, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 323, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 306 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 340 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 306 } ], "minimum": 306, "maximum": 340 } ] }, { "description": "JUGGERLOC CANNULA KIT ZIMMERBIOMET", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 896, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 425.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 403.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 448 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 403.2 } ], "minimum": 403.2, "maximum": 448 } ] }, { "description": "NITINOL LOOP PASSER ZIMMERBIOM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 728, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 327.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 364 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 327.6 } ], "minimum": 327.6, "maximum": 364 } ] }, { "description": "FLEX OSTEOTOME BLADE 10MM ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 499.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 237.22, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 224.73 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 249.7 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 224.73 } ], "minimum": 224.73, "maximum": 249.7 } ] }, { "description": "LARGE STEPPED DRILL BIT ORTHOFIX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1073.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 509.96, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 483.12 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 536.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 483.12 } ], "minimum": 483.12, "maximum": 536.8 } ] }, { "description": "PIN 1.6MM X 15MM THREADED MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 500, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 237.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 225 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 250 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 225 } ], "minimum": 225, "maximum": 250 } ] }, { "description": "INTRACEPT ACCESS INSTRUMENTS", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9600, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4560, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4320 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4800 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4320 } ], "minimum": 4320, "maximum": 4800 } ] }, { "description": "NONINVASIVE BATTERY CHARGER KIT ABBOTT", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6000, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2850, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2700 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2700 } ], "minimum": 2700, "maximum": 3000 } ] }, { "description": "OMNICURVE 20MM FRACTURE KIT", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9200, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4370, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4140 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4600 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4140 } ], "minimum": 4140, "maximum": 4600 } ] }, { "description": "BEVEL STYLET 10G STRYKER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 200, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 95, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 90 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 100 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 90 } ], "minimum": 90, "maximum": 100 } ] }, { "description": "ACL DISPOSABLE INST KIT ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1400, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 665, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 630 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 700 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 630 } ], "minimum": 630, "maximum": 700 } ] }, { "description": "DRILL BIT SOLID CORE AO/QC 3.OMM MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 400, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 190, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 180 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 200 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 180 } ], "minimum": 180, "maximum": 200 } ] }, { "description": "LOCKING/COMPRESSION DRIVER ORTHOFIX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 193.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 91.96, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 87.12 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 96.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 87.12 } ], "minimum": 87.12, "maximum": 96.8 } ] }, { "description": "ARSENAL ANKLE SCREW DRILL BIT TRILLIANT", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 860, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 408.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 387 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 430 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 387 } ], "minimum": 387, "maximum": 430 } ] }, { "description": "SWIVELOCK NANO 2.5 X 7MM ARTHREX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1239, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 588.53, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 557.55 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 619.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 557.55 } ], "minimum": 557.55, "maximum": 619.5 } ] }, { "description": "DRILL BIT 2.7 ZIMMER 2025", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 524.36, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 249.07, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 235.962 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 262.18 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 235.962 } ], "minimum": 235.962, "maximum": 262.18 } ] }, { "description": "KYPHON CEMENT DELIVERY SYS MEDTRONIC NEU", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1460.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 693.79, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 657.27 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 730.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 657.27 } ], "minimum": 657.27, "maximum": 730.3 } ] }, { "description": "KYPHON CEMENT CARTRIDGE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 294.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 140.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 132.66 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 147.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 132.66 } ], "minimum": 132.66, "maximum": 147.4 } ] }, { "description": "DRILL BIT CANNULATED AO/QC 3.3MM MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 680, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 323, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 306 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 340 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 306 } ], "minimum": 306, "maximum": 340 } ] }, { "description": "GUIDEPIN NON-THREADED 2.0 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 160, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 76, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 72 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 80 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 72 } ], "minimum": 72, "maximum": 80 } ] }, { "description": "D-STAT FLOWABLE HEMOSTAT", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 704, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 334.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 316.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 352 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 316.8 } ], "minimum": 316.8, "maximum": 352 } ] }, { "description": "CATHETER COUDE TIEMANN 18F 5CC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 47.85, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 22.73, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 21.5325 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.925 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.5325 } ], "minimum": 21.5325, "maximum": 23.925 } ] }, { "description": "SUTURE VICRYL 4-0 RB-1", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.45, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.06, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.9025 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.225 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.9025 } ], "minimum": 2.9025, "maximum": 3.225 } ] }, { "description": "BLADE DISPOSABLE #11 MCK", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.13, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.01, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.9585 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.065 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.9585 } ], "minimum": 0.9585, "maximum": 1.065 } ] }, { "description": "BANDAGE ESMARK LF PER SRT 6", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15.86, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 7.53, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7.137 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.93 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.137 } ], "minimum": 7.137, "maximum": 7.93 } ] }, { "description": "STRIP PACKING IODFRM 1 X 5YD", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.92, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.61, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.264 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.96 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.264 } ], "minimum": 6.264, "maximum": 6.96 } ] }, { "description": "DRAIN ROUND 3/4 FLUTD 15FR MCK", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 69.65, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 33.08, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 31.3425 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 34.825 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 31.3425 } ], "minimum": 31.3425, "maximum": 34.825 } ] }, { "description": "TUBING BLOOD SET W HAND PUMP CARDINAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 22.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 10.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.044 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.044 } ], "minimum": 10.044, "maximum": 11.16 } ] }, { "description": "TUBE ENDOTRACH CUFF W/STYLE 8.0MM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.51, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.99, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.7295 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.255 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.7295 } ], "minimum": 4.7295, "maximum": 5.255 } ] }, { "description": "OMNI FLUSH ANGIO 5FR 90CM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 75.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 35.91, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 34.02 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 37.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 34.02 } ], "minimum": 34.02, "maximum": 37.8 } ] }, { "description": "IV DRESSING BIOPATCH 1 INCH", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21.24, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 10.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9.558 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.62 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.558 } ], "minimum": 9.558, "maximum": 10.62 } ] }, { "description": "SUCTION COAG BOVIE MCK", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 31.86, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 15.13, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 14.337 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.93 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.337 } ], "minimum": 14.337, "maximum": 15.93 } ] }, { "description": "CATHETER FOLEY ALL SIL 12FR 5CC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14.26, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.77, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.417 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.13 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.417 } ], "minimum": 6.417, "maximum": 7.13 } ] }, { "description": "FIBERWIRE #2 ARTHREX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 92.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 43.89, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 41.58 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 46.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 41.58 } ], "minimum": 41.58, "maximum": 46.2 } ] }, { "description": "TUBE ENDOTRACHEAL CUFFED 5.0 MCK", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.94, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.123 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.47 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.123 } ], "minimum": 3.123, "maximum": 3.47 } ] }, { "description": "4.0 ARTHREX SLAP BURR", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 200, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 95, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 90 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 100 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 90 } ], "minimum": 90, "maximum": 100 } ] }, { "description": "3.8 ARTHREX WHISKER SHAVER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 176, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 83.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 79.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 88 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 79.2 } ], "minimum": 79.2, "maximum": 88 } ] }, { "description": "SINGLE USE INJECTOR", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 159.72, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.87, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 71.874 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 79.86 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 71.874 } ], "minimum": 71.874, "maximum": 79.86 } ] }, { "description": "STRYKER BURR OVAL 4.0MM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 97.16, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 46.15, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 43.722 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 48.58 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 43.722 } ], "minimum": 43.722, "maximum": 48.58 } ] }, { "description": "SUTURE LASSO WIRE LOOP ARTHREX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 117.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 55.86, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 52.92 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 58.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 52.92 } ], "minimum": 52.92, "maximum": 58.8 } ] }, { "description": "CUTTING LOOP 27F PROSURGE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 280, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 133, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 126 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 140 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 126 } ], "minimum": 126, "maximum": 140 } ] }, { "description": "MEROCEL LAMINATED NASAL DR 8CM MEDTRONIC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 87.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 41.61, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 39.42 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 43.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 39.42 } ], "minimum": 39.42, "maximum": 43.8 } ] }, { "description": "LONESTAR RETRACTOR RING 32.5CM X 18.3CM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 201.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 95.63, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 90.594 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 100.66 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 90.594 } ], "minimum": 90.594, "maximum": 100.66 } ] }, { "description": "PERFORMATRAC FULL FACE MASK (M)", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.12, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 47.56, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 45.054 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 50.06 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 45.054 } ], "minimum": 45.054, "maximum": 50.06 } ] }, { "description": "SUTURE SILK 3-0 SH", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.376 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.376 } ], "minimum": 2.376, "maximum": 2.64 } ] }, { "description": "CATHETER 20 FR COUNCIL TIP 5CC BAL MEDLI", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.12, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 23.81, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 22.554 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.06 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.554 } ], "minimum": 22.554, "maximum": 25.06 } ] }, { "description": "COLOSTOMY BAG 2 3/4 MCK", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.36, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.512 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.68 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.512 } ], "minimum": 1.512, "maximum": 1.68 } ] }, { "description": "STOPCOCK 3-WAY ROTATING MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.77, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.74, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.5965 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.885 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.5965 } ], "minimum": 2.5965, "maximum": 2.885 } ] }, { "description": "VENTI AIR MASK CHIN ON SIZE MCK", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.72, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.19, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.024 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.36 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.024 } ], "minimum": 3.024, "maximum": 3.36 } ] }, { "description": "SPO2 SENSOR INFANT DISPOSABLE CARDINAL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 38.31, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 18.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 17.2395 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.155 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.2395 } ], "minimum": 17.2395, "maximum": 19.155 } ] }, { "description": "EPIDURAL CATHETER PERIFIX 20 GAUGE BRAUN", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 30.24, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 14.36, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 13.608 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.12 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.608 } ], "minimum": 13.608, "maximum": 15.12 } ] }, { "description": "SPD - SUTURE STEEL 18 GAUGE 18 MCK", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 15.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 14.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.4 } ], "minimum": 14.4, "maximum": 16 } ] }, { "description": "ROD LENS SCOPE SEALS HOLOGIC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 40, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 19, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 18 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 20 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 18 } ], "minimum": 18, "maximum": 20 } ] }, { "description": "SUCTION TIP FRAZIER 10 FR DISPOSABL", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.51, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.62, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.4795 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.755 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.4795 } ], "minimum": 2.4795, "maximum": 2.755 } ] }, { "description": "BLADE RECIP SAW HEAVY DUTY LONG", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 187.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 88.96, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 84.276 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 93.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 84.276 } ], "minimum": 84.276, "maximum": 93.64 } ] }, { "description": "ADVANCED NOVASURE DEVICE HOLOGIC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4900, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2327.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2205 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2450 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2205 } ], "minimum": 2205, "maximum": 2450 } ] }, { "description": "100MM BLADE DUAL CUT SAG SAW STRYKER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 196.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 93.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 88.578 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 98.42 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 88.578 } ], "minimum": 88.578, "maximum": 98.42 } ] }, { "description": "SUTURE #1 VICRYL CT-1 27 JOHNSON AND JO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.12, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.43, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.304 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.56 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.304 } ], "minimum": 2.304, "maximum": 2.56 } ] }, { "description": "DISPOSABLE EYE BLADE SIGHTPATH", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 73.44, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 34.88, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 33.048 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 36.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 33.048 } ], "minimum": 33.048, "maximum": 36.72 } ] }, { "description": "PUREWICK FEMALE CATHETER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 31.64, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 15.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 14.238 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.82 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.238 } ], "minimum": 14.238, "maximum": 15.82 } ] }, { "description": "DRILL BIT MIS 3.0MM PRECISION ROUND HEAD", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 776.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 368.87, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 349.452 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 388.28 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 349.452 } ], "minimum": 349.452, "maximum": 388.28 } ] }, { "description": "LONESTAR ELASTIC STAY FOR RETRACTOR RING", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 402.64, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 191.25, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 181.188 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 201.32 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 181.188 } ], "minimum": 181.188, "maximum": 201.32 } ] }, { "description": "BLADE ELECTRODE 4 SILICONE MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.76, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.39, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.892 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.88 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.892 } ], "minimum": 8.892, "maximum": 9.88 } ] }, { "description": "OPTILUME BALLOON DILATION CATHETER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1260, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 598.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 567 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 630 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 567 } ], "minimum": 567, "maximum": 630 } ] }, { "description": "ENDOTRACHEAL TUBE CUFFED 4.0", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.99, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.78 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.78 } ], "minimum": 3.78, "maximum": 4.2 } ] }, { "description": "ABD BINDER 62-73 (12 4-PANEL)", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 34, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.15, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.3 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.3 } ], "minimum": 15.3, "maximum": 17 } ] }, { "description": "ABD BINDER 62-73 (9 3-PANEL)", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 32.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 15.35, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 14.544 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.544 } ], "minimum": 14.544, "maximum": 16.16 } ] }, { "description": "DRAIN FLAT FULL FLUTED 10FR MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 41.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 19.74, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 18.702 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.78 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.702 } ], "minimum": 18.702, "maximum": 20.78 } ] }, { "description": "SUTURE 90DEG LASSO ARTHREX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 588, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 279.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 264.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 294 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 264.6 } ], "minimum": 264.6, "maximum": 294 } ] }, { "description": "KYPHYON T34A INTRODUCER SYSTEM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3326.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1580.04, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1496.88 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1663.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1496.88 } ], "minimum": 1496.88, "maximum": 1663.2 } ] }, { "description": "VITRECTOMY PACK USED IN EYE PROCEDURE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 816, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 387.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 367.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 408 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 367.2 } ], "minimum": 367.2, "maximum": 408 } ] }, { "description": "EXPO LCB 6 FR", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.84 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.84 } ], "minimum": 15.84, "maximum": 17.6 } ] }, { "description": "TRAILBLAZER SUPPORT CATHETER 035 EV3", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 600, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 285, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 270 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 300 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 270 } ], "minimum": 270, "maximum": 300 } ] }, { "description": "DISC FX MINIMALLY INVASIVE SYSTEM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7800, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3705, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3510 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3900 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3510 } ], "minimum": 3510, "maximum": 3900 } ] }, { "description": "NEEDLE SPINAL 16GAUGE FOR DISC FX SYSTE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 200, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 95, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 90 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 100 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 90 } ], "minimum": 90, "maximum": 100 } ] }, { "description": "DISCMONITOR STRYKER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2044.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 971.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 919.926 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1022.14 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 919.926 } ], "minimum": 919.926, "maximum": 1022.14 } ] }, { "description": "DRILL BIT 1.5 ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 318.24, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 151.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 143.208 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 159.12 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 143.208 } ], "minimum": 143.208, "maximum": 159.12 } ] }, { "description": "DRILL BIT 2.8MM SYNTHES", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 948, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 450.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 426.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 474 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 426.6 } ], "minimum": 426.6, "maximum": 474 } ] }, { "description": "EXPO FL3.5 6FR BOSTON SCIENTIFIC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.84 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.84 } ], "minimum": 15.84, "maximum": 17.6 } ] }, { "description": "CATHETER PASSER MEDTRONIC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 452, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 214.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 203.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 226 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 203.4 } ], "minimum": 203.4, "maximum": 226 } ] }, { "description": "DRILL BITS 1.9 FIXATION MEDARTIS", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 468.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 222.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 210.87 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 234.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 210.87 } ], "minimum": 210.87, "maximum": 234.3 } ] }, { "description": "NEEDLE 4 IN BOSTON SCIENTIFIC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 600, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 285, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 270 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 300 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 270 } ], "minimum": 270, "maximum": 300 } ] }, { "description": "DRILL BIT 2.5MM CALIBRATED ARTHREX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 357, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 169.58, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 160.65 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 178.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 160.65 } ], "minimum": 160.65, "maximum": 178.5 } ] }, { "description": "CATHETER ACCESS KIT MEDTRONIC", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 128, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 60.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 57.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 57.6 } ], "minimum": 57.6, "maximum": 64 } ] }, { "description": "DRILL BIT 2.5MM ARTHREX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 357, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 169.58, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 160.65 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 178.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 160.65 } ], "minimum": 160.65, "maximum": 178.5 } ] }, { "description": "TAPERS CURVED 26MM NEEDLE 1/2 CIRCLE/LOO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 79.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 37.91, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 35.91 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 39.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 35.91 } ], "minimum": 35.91, "maximum": 39.9 } ] }, { "description": "EZ PASS 90 DEGREE UP ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1148, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 545.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 516.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 574 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 516.6 } ], "minimum": 516.6, "maximum": 574 } ] }, { "description": "ENTRY DRILL 7MM ORTHOFIX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1460.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 693.88, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 657.36 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 730.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 657.36 } ], "minimum": 657.36, "maximum": 730.4 } ] }, { "description": "ENTRY DRILL 9MM ORTHOFIX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1460.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 693.88, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 657.36 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 730.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 657.36 } ], "minimum": 657.36, "maximum": 730.4 } ] }, { "description": "ENTRY REAMER 13MM ORTHOFIX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1460.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 693.88, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 657.36 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 730.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 657.36 } ], "minimum": 657.36, "maximum": 730.4 } ] }, { "description": "LOW PROFILE REAMER 9MM 2021 ARTHREX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 819, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 389.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 368.55 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 409.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 368.55 } ], "minimum": 368.55, "maximum": 409.5 } ] }, { "description": "DRILL BIT 2.5 ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 324.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 154.19, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 146.07 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 162.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 146.07 } ], "minimum": 146.07, "maximum": 162.3 } ] }, { "description": "DRILL BIT 2.7 ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 514.08, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 244.19, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 231.336 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 257.04 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 231.336 } ], "minimum": 231.336, "maximum": 257.04 } ] }, { "description": "DRILL BIT CANNULATED LONG MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 680, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 323, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 306 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 340 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 306 } ], "minimum": 306, "maximum": 340 } ] }, { "description": "LARGE BONE BLADE 1.27MM SAGITTAL STRYKER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 252.96, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 120.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 113.832 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 126.48 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 113.832 } ], "minimum": 113.832, "maximum": 126.48 } ] }, { "description": "HAND DRILL STRYKER 2022", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 254, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 120.65, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 114.3 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 127 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 114.3 } ], "minimum": 114.3, "maximum": 127 } ] }, { "description": "LAPIPLASTY SAW BLADE 40MMX11MM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 200, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 95, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 90 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 100 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 90 } ], "minimum": 90, "maximum": 100 } ] }, { "description": "AVAFLEX CURVED NEEDLE STRYKER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1881, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 893.48, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 846.45 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 940.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 846.45 } ], "minimum": 846.45, "maximum": 940.5 } ] }, { "description": "TAP PACK FOR 4.75MM SUTURE ANCHOR OSSIO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1000, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 475, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 450 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 450 } ], "minimum": 450, "maximum": 500 } ] }, { "description": "DRILL BIT 1.6 FIXATION AO MEDARTIS", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 468.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 222.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 210.87 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 234.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 210.87 } ], "minimum": 210.87, "maximum": 234.3 } ] }, { "description": "DRILL KIT 4.75MM SUTURE ANCHOR OSSIO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1700, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 807.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 765 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 850 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 765 } ], "minimum": 765, "maximum": 850 } ] }, { "description": "OMNICURVE 15MM FRACTURE KIT", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9200, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4370, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4140 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4600 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4140 } ], "minimum": 4140, "maximum": 4600 } ] }, { "description": "DISPOSABLE SURGICAL CABLE SJM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 120, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 57, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 54 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 60 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 54 } ], "minimum": 54, "maximum": 60 } ] }, { "description": "TRIGGER FLEX DART PROBE ELLIQUENCE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2200, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1045, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 990 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1100 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 990 } ], "minimum": 990, "maximum": 1100 } ] }, { "description": "DRILL BIT ELLIQUENCE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1820, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 864.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 819 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 910 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 819 } ], "minimum": 819, "maximum": 910 } ] }, { "description": "SUPPORT TUBES ELLIQUENCE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1180, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 560.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 531 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 590 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 531 } ], "minimum": 531, "maximum": 590 } ] }, { "description": "DRILL BIT 2.0 CANNULATED AO/QC MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 680, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 323, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 306 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 340 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 306 } ], "minimum": 306, "maximum": 340 } ] }, { "description": "TRIGGER FLEX DART PROBE ELLIQUENCE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2720, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1292, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1224 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1360 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1224 } ], "minimum": 1224, "maximum": 1360 } ] }, { "description": "DRILL BIT 4.8 QUICK CONNECT ORTHOFIX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1180, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 560.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 531 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 590 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 531 } ], "minimum": 531, "maximum": 590 } ] }, { "description": "DRILL BIT 2.7 QUICK CONNECT ORTHOFIX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1180, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 560.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 531 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 590 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 531 } ], "minimum": 531, "maximum": 590 } ] }, { "description": "REAMER 2.0/2.3 MEDARTIS", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1288.48, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 612.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 579.816 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 644.24 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 579.816 } ], "minimum": 579.816, "maximum": 644.24 } ] }, { "description": "DRIVER CANNULATED AO/QC T10 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1780, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 845.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 801 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 890 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 801 } ], "minimum": 801, "maximum": 890 } ] }, { "description": "BURR SHANNON RECTA 2.0 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1180, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 560.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 531 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 590 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 531 } ], "minimum": 531, "maximum": 590 } ] }, { "description": "BURR SHANNON RECTA LARGA 2.2 MEDLINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1180, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 560.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 531 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 590 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 531 } ], "minimum": 531, "maximum": 590 } ] }, { "description": "DRILL BIT CANNULATED AO/QC 2.6MM MELINE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 680, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 323, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 306 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 340 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 306 } ], "minimum": 306, "maximum": 340 } ] }, { "description": "DELIVERY CANNULA BONESUPPORT", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 800, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 380, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 360 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 400 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 360 } ], "minimum": 360, "maximum": 400 } ] }, { "description": "HEX DRIVER 3.5MM ORTHOFIX", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 193.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 91.96, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 87.12 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 96.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 87.12 } ], "minimum": 87.12, "maximum": 96.8 } ] }, { "description": "THULIO FIBER SINGLEFLEX 270 SU AGILITI", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1600, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 760, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 720 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 800 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 720 } ], "minimum": 720, "maximum": 800 } ] }, { "description": "CERAMENT BEAD TRAY BONESUPPORT", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 600, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 285, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 270 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 300 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 270 } ], "minimum": 270, "maximum": 300 } ] }, { "description": "KIT BIO T DISP", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 819, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 389.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 368.55 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 409.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 368.55 } ], "minimum": 368.55, "maximum": 409.5 } ] }, { "description": "CLEARMIX SINGLE DOUBLE MIX CEMENT ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 393.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 186.83, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 176.994 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 196.66 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 176.994 } ], "minimum": 176.994, "maximum": 196.66 } ] }, { "description": "PEDICLE 200MM PROBE MAGSTIM NEURO MONITO", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 283.98, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 134.89, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 127.791 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 141.99 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 127.791 } ], "minimum": 127.791, "maximum": 141.99 } ] }, { "description": "ABORTED CATARACT SUPPLY KIT SIGHTPATH ME", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1020, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 484.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 459 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 510 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 459 } ], "minimum": 459, "maximum": 510 } ] }, { "description": "DRILL BIT 2.0 ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 807.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 383.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 363.528 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 403.92 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 363.528 } ], "minimum": 363.528, "maximum": 403.92 } ] }, { "description": "DRILL BIT 3.5 ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 324.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 154.19, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 146.07 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 162.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 146.07 } ], "minimum": 146.07, "maximum": 162.3 } ] }, { "description": "ARSENAL SCREW OVERDRILL BIT 2.2MM", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 860, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 408.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 387 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 430 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 387 } ], "minimum": 387, "maximum": 430 } ] }, { "description": "ARSENAL SCREW DRIVER BIT", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 860, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 408.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 387 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 430 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 387 } ], "minimum": 387, "maximum": 430 } ] }, { "description": "KYPHON KURVE CURVED BONE FILLER DEVICE", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1600, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 760, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 720 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 800 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 720 } ], "minimum": 720, "maximum": 800 } ] }, { "description": "DRILL CANNULATED TRINKLE END", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1954.64, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 928.45, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 879.588 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 977.32 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 879.588 } ], "minimum": 879.588, "maximum": 977.32 } ] }, { "description": "TAP Q-C FOR SCREWS 6.5 ZIMMER", "code_information": [ { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 649.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 308.37, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 292.14 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 324.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 292.14 } ], "minimum": 292.14, "maximum": 324.6 } ] }, { "description": "IMPLANT X-LINK 75MM LUMBAR VY SPINE", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3332, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 999.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1832.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1666 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1499.4 } ], "minimum": 999.6, "maximum": 1832.6 } ] }, { "description": "IMPLANT CONNEXUS 10 CC DBM PUTTY SEASPI", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4160, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1248, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2288 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2080 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1872 } ], "minimum": 1248, "maximum": 2288 } ] }, { "description": "K-WIRE TROCAR PT DBL END 1.1 ZIMMER DNO", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 32.64, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 9.79, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 17.952 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.32 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.688 } ], "minimum": 9.79, "maximum": 17.952 } ] }, { "description": "IMPLANT 1 LEVEL PLATE CERVICAL VY SPINE", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 940.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1724.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 940.8, "maximum": 1724.8 } ] }, { "description": "K-WIRE 2.4mm (.094) ZIMMER", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 44.88, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 13.46, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 24.684 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.44 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.196 } ], "minimum": 13.46, "maximum": 24.684 } ] }, { "description": "IMPLANT CANCELLOUS CHIPS 4-10 30CC SEASP", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1600, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 480, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 880 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 800 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 720 } ], "minimum": 480, "maximum": 880 } ] }, { "description": "IMPLANT CONNEXUS 1CC DBM PUTTY SEASPINE", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 660, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 198, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 363 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 330 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 297 } ], "minimum": 198, "maximum": 363 } ] }, { "description": "IMPLANT CANCELLOUS CHIPS 4-10 15CC SEASP", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1000, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 300, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 550 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 450 } ], "minimum": 300, "maximum": 550 } ] }, { "description": "GUIDEWIRE 3.0 X 800 ORTHOFIX", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 932.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 279.84, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 513.04 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 466.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 419.76 } ], "minimum": 279.84, "maximum": 513.04 } ] }, { "description": "DOUBLE ENDED K-WIRE 1.6mm (.063) ZIMMER", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 32.64, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 9.79, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 17.952 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.32 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.688 } ], "minimum": 9.79, "maximum": 17.952 } ] }, { "description": "K-WIRE 2.8mm (.109) ZIMMER", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 27.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 8.34, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.29 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.51 } ], "minimum": 8.34, "maximum": 15.29 } ] }, { "description": "IMPLANT 1 LEVL PLATE CERVICAL 2020 GCSDM", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 940.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1724.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 940.8, "maximum": 1724.8 } ] }, { "description": "IMPLANT 3.0 CANNULATED TRIMMABLE NAIL", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6340, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1902, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3487 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3170 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2853 } ], "minimum": 1902, "maximum": 3487 } ] }, { "description": "IMPLANT CONNEXUS 5 CC DBM PUTTY SEASPI", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2000, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 600, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1100 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 900 } ], "minimum": 600, "maximum": 1100 } ] }, { "description": "GUIDEWIRE 2.5 X 800 ORTHOFIX", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 932.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 279.84, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 513.04 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 466.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 419.76 } ], "minimum": 279.84, "maximum": 513.04 } ] }, { "description": "HEALIX ADVANCE SP PEEK ANCHOR 4.9MM", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2219.52, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 665.86, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1220.736 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1109.76 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 998.784 } ], "minimum": 665.86, "maximum": 1220.736 } ] }, { "description": "IMPLANT 3.0 CANNULATED TRIMMABLE DISC", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2800, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 840, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1540 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1400 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1260 } ], "minimum": 840, "maximum": 1540 } ] }, { "description": "INSTR KIT SM JNT S-TAK ARTHRE", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 609, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 182.7, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 334.95 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 304.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 274.05 } ], "minimum": 182.7, "maximum": 334.95 } ] }, { "description": "IMPLANT MTP FUSION REV PLATE RIGHT MEDLI", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6000, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1800, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3300 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2700 } ], "minimum": 1800, "maximum": 3300 } ] }, { "description": "IMPLANT ALIF SACRAL PLATE GCDM", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6036.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 3292.8, "maximum": 6036.8 } ] }, { "description": "IMPLANT 2.3 HEX 5.5MM THREADED NAIL OSSI", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5840, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1752, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 2640, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3212 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2920 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2628 } ], "minimum": 1752, "maximum": 3212 } ] }, { "description": "IMPLANT 5.5 THREADED FIXATION NAIL", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7780, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 2334, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1248, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4279 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3890 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3501 } ], "minimum": 1248, "maximum": 4279 } ] }, { "description": "IMPLANT SYN REPAR K-LESS T-ROPE W/DRIVE", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6279, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1883.7, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1134, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3453.45 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3139.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2825.55 } ], "minimum": 1134, "maximum": 3453.45 } ] }, { "description": "IMPLANT K-WIRE 0.8 TROCAR MEDARTIS", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 121.48, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 36.44, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 674.18, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 66.814 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 60.74 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 54.666 } ], "minimum": 36.44, "maximum": 674.18 } ] }, { "description": "IMPLANT BONALIVE 10CC LG ORTHO GRANULES", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1734", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15480, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 4644, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8514 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7740 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6966 } ], "minimum": 4644, "maximum": 8514 } ] }, { "description": "IMPLANT BONALIVE 1 CC LG ORTHO GRANULES", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1734", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4000, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1200, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2200 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1800 } ], "minimum": 1200, "maximum": 2200 } ] }, { "description": "IMPLANT BONALIVE 5CC ORTHO GRANULES TRIM", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1734", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10460, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 3138, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5753 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5230 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4707 } ], "minimum": 3138, "maximum": 5753 } ] }, { "description": "IMPLANT BONALIVE 2.5CC ORTHO GRANULES T", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1734", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7720, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 2316, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4246 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3860 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3474 } ], "minimum": 2316, "maximum": 4246 } ] }, { "description": "IMPLANT BONALIVE 5CC LG ORTHO GRANULES", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1734", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10460, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 3138, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 813.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5753 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5230 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4707 } ], "minimum": 813.6, "maximum": 5753 } ] }, { "description": "IMPLANT VIA DISC 100MG VIVEX BIOLOGICS", "code_information": [ { "code": "278", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 32000, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 9600, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 17600 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 14400 } ], "minimum": 9600, "maximum": 17600 } ] }, { "description": "IMPLANT INFUSE XXSMALL BONE GRAFT", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2712, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 813.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1491.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1356 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1220.4 } ], "minimum": 813.6, "maximum": 1491.6 } ] }, { "description": "IMPLANT SPONGE STRIP 20X50 TIDES", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7980, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 2394, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4389 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3990 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3591 } ], "minimum": 2394, "maximum": 4389 } ] }, { "description": "IMPLANT TRINITY ELITE MEDIUM BONE GRAFT", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8800, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 2640, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4840 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4400 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3960 } ], "minimum": 2640, "maximum": 4840 } ] }, { "description": "IMPLANT EVEREST SET SCREW STRYKER SPINE", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 196, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 58.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 107.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 98 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 88.2 } ], "minimum": 58.8, "maximum": 107.8 } ] }, { "description": "IMPLANT BENT ROD VY SPINE", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 784, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 235.2, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 431.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 392 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.8 } ], "minimum": 235.2, "maximum": 431.2 } ] }, { "description": "IMPLANT VALENCIA MIS CURVED ROD ALTUS SP", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1176, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 352.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 646.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 588 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 529.2 } ], "minimum": 352.8, "maximum": 646.8 } ] }, { "description": "IMPLANT CURVED ROD ALTUS SPINE", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 705.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 211.68, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 388.08 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 317.52 } ], "minimum": 211.68, "maximum": 388.08 } ] }, { "description": "IMPLANT TRINITY ELITE SMALL BONE GRAFT", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1980, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 594, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1089 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 990 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 891 } ], "minimum": 594, "maximum": 1089 } ] }, { "description": "PE TUBE SHEEHY MEDTRONIC", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 79.02, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 23.71, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 43.461 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 39.51 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 35.559 } ], "minimum": 23.71, "maximum": 43.461 } ] }, { "description": "IMPLANT INFUSE BONE GRAFT MED", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12800, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 3840, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7040 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6400 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5760 } ], "minimum": 3840, "maximum": 7040 } ] }, { "description": "WRENCH BREAK AWAY ZIMMER", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 374.56, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 112.37, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 206.008 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 187.28 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 168.552 } ], "minimum": 112.37, "maximum": 206.008 } ] }, { "description": "IMPLANT TRINITY ELITE LARGE BONE GRAFT", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15580, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 4674, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8569 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7790 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7011 } ], "minimum": 4674, "maximum": 8569 } ] }, { "description": "IMPLANT SPONGE CUBE 10MM TIDES MEDICAL", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3780, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1134, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2079 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1890 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1701 } ], "minimum": 1134, "maximum": 2079 } ] }, { "description": "XTRAFIX BAR TO BAR CLAMP 3-D ZIMMER", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2247.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 674.18, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1236.004 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1123.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1011.276 } ], "minimum": 674.18, "maximum": 1236.004 } ] }, { "description": "INTRATHECAL CATHETER MEDTRONIC", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4000, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1200, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2200 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1800 } ], "minimum": 1200, "maximum": 2200 } ] }, { "description": "IMPLANT GRAFT SUBS BONE FIBER LARGE", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5496, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1648.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3022.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2748 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2473.2 } ], "minimum": 1648.8, "maximum": 3022.8 } ] }, { "description": "TACHOSIL FIBRIN SEALANT PATCH 4X4", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1818, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 545.4, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 999.9 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 909 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 818.1 } ], "minimum": 545.4, "maximum": 999.9 } ] }, { "description": "SURGICAL POWDER 1GRAM RX CELLERATE", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1820, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 546, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1001 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 910 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 819 } ], "minimum": 546, "maximum": 1001 } ] }, { "description": "DURAGEN PLUS 1X3 INTERGRA", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1394.08, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 418.22, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 766.744 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 697.04 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 627.336 } ], "minimum": 418.22, "maximum": 766.744 } ] }, { "description": "IMPLANT TRINITY ELITE GRAFT XL MTF", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19980, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 5994, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10989 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9990 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8991 } ], "minimum": 5994, "maximum": 10989 } ] }, { "description": "EXTENSION CABLE KIT 978VTS INTERSTIM MED", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1125.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 337.75, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 619.212 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 562.92 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 506.628 } ], "minimum": 337.75, "maximum": 619.212 } ] }, { "description": "OR CABLE 1X16 BOSTON SCIENTIFIC", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1.2, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.8 } ], "minimum": 1.2, "maximum": 2.2 } ] }, { "description": "IMPLANT COCR PRE BENT ROD", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 705.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 211.68, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 388.08 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 317.52 } ], "minimum": 211.68, "maximum": 388.08 } ] }, { "description": "BONE WAX", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 22.19, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 6.66, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 12.2045 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.095 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.9855 } ], "minimum": 6.66, "maximum": 12.2045 } ] }, { "description": "TIGER WIRE #2 ARTHREX", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 189, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 56.7, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 103.95 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 94.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 85.05 } ], "minimum": 56.7, "maximum": 103.95 } ] }, { "description": "DRILL SLEEVE 2.0MM ARTHREX", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 147, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 44.1, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 80.85 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 73.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 66.15 } ], "minimum": 44.1, "maximum": 80.85 } ] }, { "description": "IMPLANT TRUELOK SYS HALF PIN QUICK CONNE", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1512, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 453.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 831.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 756 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 680.4 } ], "minimum": 453.6, "maximum": 831.6 } ] }, { "description": "IMPLANT ZVPRO PUTTY 2.5CC ZAVATION", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1264, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 379.2, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 695.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 632 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 568.8 } ], "minimum": 379.2, "maximum": 695.2 } ] }, { "description": "IMPLANT GRAFT SUBS BONE FIBER X-SMALL", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1028, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 308.4, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 565.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 514 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 462.6 } ], "minimum": 308.4, "maximum": 565.4 } ] }, { "description": "PE TUBE T-TUBE MEDTRONIC", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 108.04, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 32.41, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 59.422 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 54.02 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 48.618 } ], "minimum": 32.41, "maximum": 59.422 } ] }, { "description": "IMPLANT GUIDE WIRE VILEX", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 80, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 24, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 44 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 40 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 36 } ], "minimum": 24, "maximum": 44 } ] }, { "description": "PATIENT CONTROLLER ABBOTT", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2000, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 600, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1100 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 900 } ], "minimum": 600, "maximum": 1100 } ] }, { "description": "IMPLANT GRAFT SUBS BONE FIBER MEDIUM", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3016, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 904.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1658.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1508 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1357.2 } ], "minimum": 904.8, "maximum": 1658.8 } ] }, { "description": "IMPLANT SWIVELOCK NANO 7MM W/FORK EYELET", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2205, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 661.5, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1212.75 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1102.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 992.25 } ], "minimum": 661.5, "maximum": 1212.75 } ] }, { "description": "IMPLANT SUTURETAPE FIBERLINK ARTHREX", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 340, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 102, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 187 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 170 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 153 } ], "minimum": 102, "maximum": 187 } ] }, { "description": "IMPLANT AX ALIF SCREW 5.5 INNOVASIS", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1176, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 352.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 646.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 588 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 529.2 } ], "minimum": 352.8, "maximum": 646.8 } ] }, { "description": "CABLE READY CABLE ASSY ZIMMER", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1573.08, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 471.92, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 865.194 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 786.54 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 707.886 } ], "minimum": 471.92, "maximum": 865.194 } ] }, { "description": "FREELINK REMOTE CONTROL KIT BOSTON", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3200, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 960, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1760 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1600 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1440 } ], "minimum": 960, "maximum": 1760 } ] }, { "description": "IMPLANT VERSAGRAFT 220MM GRACILIS", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5320, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1596, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2926 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2660 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2394 } ], "minimum": 1596, "maximum": 2926 } ] }, { "description": "SURGICAL POWDER 5GRAM RX CELLERATE", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5980, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1794, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3289 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2990 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2691 } ], "minimum": 1794, "maximum": 3289 } ] }, { "description": "PREVENTOGEN ANTIMICROBIAL ADHESIVE ORTHO", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5800, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1740, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3190 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2900 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2610 } ], "minimum": 1740, "maximum": 3190 } ] }, { "description": "TRUELOK 1.8MM SMOOTH WIRE ORTHOFIX", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 780, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 234, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 429 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 390 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 351 } ], "minimum": 234, "maximum": 429 } ] }, { "description": "IMPLANT ZVPRO PUTTY 5CC ZAVATION", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2080, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 624, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1144 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1040 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 936 } ], "minimum": 624, "maximum": 1144 } ] }, { "description": "IMPLANT BONUS TRIAD 10CC", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16548.48, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 4964.54, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9101.664 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 8274.24 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7446.816 } ], "minimum": 4964.54, "maximum": 9101.664 } ] }, { "description": "BIOCOMPOSITE 3.9 17.9MM SWIVELOCK", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1680, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 504, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 924 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 840 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 756 } ], "minimum": 504, "maximum": 924 } ] }, { "description": "iPRISM CLIP FOR iSTENT CASE", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 142.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 42.84, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 78.54 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 71.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 64.26 } ], "minimum": 42.84, "maximum": 78.54 } ] }, { "description": "IMPLANT SUTURETAPE 1.3MM WH/BLK WH/BLK", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 273, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 81.9, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 150.15 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 136.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 122.85 } ], "minimum": 81.9, "maximum": 150.15 } ] }, { "description": "BUTTON BICEPS ARTHEX", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1239, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 371.7, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 681.45 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 619.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 557.55 } ], "minimum": 371.7, "maximum": 681.45 } ] }, { "description": "IMPLANT BOWLINE 10CC DBM PUTTY TIDESMED", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4160, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1248, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2288 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2080 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1872 } ], "minimum": 1248, "maximum": 2288 } ] }, { "description": "COUNTERSINK 4.5 HEADLESS CANN AO/QC MEDL", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 525, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 157.5, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 288.75 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 262.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 236.25 } ], "minimum": 157.5, "maximum": 288.75 } ] }, { "description": "INTRACEPT RF PROBE RELIEVANT", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18400, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 5520, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10120 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9200 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8280 } ], "minimum": 5520, "maximum": 10120 } ] }, { "description": "IMPLANT TYREX ANTIMICROBIAL ENV MEDIUM", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3980, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1194, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2189 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1990 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1791 } ], "minimum": 1194, "maximum": 2189 } ] }, { "description": "COUNTERSINK 3.0 MIS CANN AO/QC MEDL", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 700, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 210, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 385 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 350 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 315 } ], "minimum": 210, "maximum": 385 } ] }, { "description": "IMPLANT TL+ HALF PIN 5MM", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 739.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 221.76, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 406.56 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 369.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 332.64 } ], "minimum": 221.76, "maximum": 406.56 } ] }, { "description": "IMPLANT STENT 7FR X 26", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 247.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 74.18, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 136.004 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 123.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 111.276 } ], "minimum": 74.18, "maximum": 136.004 } ] }, { "description": "XTRAFIX 45MM PIN CLAMP 2-BAR", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5043.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1513.15, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2774.112 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2521.92 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2269.728 } ], "minimum": 1513.15, "maximum": 2774.112 } ] }, { "description": "XTRAFIX 90 DEG ANGLED POST 11MM ZIMMER", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 524.36, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 157.31, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 288.398 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 262.18 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 235.962 } ], "minimum": 157.31, "maximum": 288.398 } ] }, { "description": "XTRAFIX 11 X 100MM BAR ZIMMER", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 674.16, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 202.25, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 370.788 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 337.08 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 303.372 } ], "minimum": 202.25, "maximum": 370.788 } ] }, { "description": "IMPLANT BB-TAK ARTHREX", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 210, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 63, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 115.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 105 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 94.5 } ], "minimum": 63, "maximum": 115.5 } ] }, { "description": "IMPLANT I-FACTOR 2.5CC PUTTY CERAPEDICS", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5800, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1740, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3190 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2900 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2610 } ], "minimum": 1740, "maximum": 3190 } ] }, { "description": "HEX WRENCH BOSTON SCIENTIFIC", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 160, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 48, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 88 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 80 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 72 } ], "minimum": 48, "maximum": 88 } ] }, { "description": "IMPLANT SWIFT LOCK ABBOTT 1192", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 500, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 150, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 275 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 250 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 225 } ], "minimum": 150, "maximum": 275 } ] }, { "description": "IMPLANT GRAFT COASTAL CARTILAGE NUTECH", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1868, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 560.4, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1027.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 934 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 840.6 } ], "minimum": 560.4, "maximum": 1027.4 } ] }, { "description": "OR CABLE 2X8 BOSTON SCIENTIFIC", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1.2, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.8 } ], "minimum": 1.2, "maximum": 2.2 } ] }, { "description": "IMPLANT BOWLINE 5CC DBM PUTTY TIDESMEDIC", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2080, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 624, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1144 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1040 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 936 } ], "minimum": 624, "maximum": 1144 } ] }, { "description": "IMPLANT AMINO HEAL PLUS 4x4 TIDES", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8780, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 2634, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4829 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4390 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3951 } ], "minimum": 2634, "maximum": 4829 } ] }, { "description": "SCREWDRIVER BLADE MEDARTIS", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 654.88, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 196.46, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 360.184 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 327.44 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 294.696 } ], "minimum": 196.46, "maximum": 360.184 } ] }, { "description": "SUTURE BUTTON TENDON ARTHREX", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 420, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 126, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 231 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 210 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 189 } ], "minimum": 126, "maximum": 231 } ] }, { "description": "LIGAMENT AUGMENT REPAIR KIT ARTHREX", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6279, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1883.7, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3453.45 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3139.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2825.55 } ], "minimum": 1883.7, "maximum": 3453.45 } ] }, { "description": "CANNULATED 6.5MM DRILL TAP ZIMME", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1747.88, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 524.36, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 961.334 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 873.94 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 786.546 } ], "minimum": 524.36, "maximum": 961.334 } ] }, { "description": "INTERSTIM TEST STIMULATION LEAD KIT", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 295.84, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 88.75, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 162.712 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 147.92 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 133.128 } ], "minimum": 88.75, "maximum": 162.712 } ] }, { "description": "INTERSTIM TEST STIMULATION LEAD", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 147.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 44.16, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 80.96 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 73.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 66.24 } ], "minimum": 44.16, "maximum": 80.96 } ] }, { "description": "IMPLANT SPEED GRAFT", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9600, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 2880, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5280 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4800 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4320 } ], "minimum": 2880, "maximum": 5280 } ] }, { "description": "IMPLANT MOZIAK STRIP 15CC SEASPINE", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4980, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1494, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2739 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2490 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2241 } ], "minimum": 1494, "maximum": 2739 } ] }, { "description": "IMPLANT 6MM CERVICAL TOTAL DISC ORTHOFIX", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18616, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 5584.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10238.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9308 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8377.2 } ], "minimum": 5584.8, "maximum": 10238.8 } ] }, { "description": "EXTENSION CABLE INTERSTIM 3560022", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1000, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 300, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 550 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 450 } ], "minimum": 300, "maximum": 550 } ] }, { "description": "IMPLANT BONUS TRIAD 5CC", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8988.24, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 2696.47, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4943.532 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4494.12 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4044.708 } ], "minimum": 2696.47, "maximum": 4943.532 } ] }, { "description": "IMPLANT DNE CIRCULAR/SPEED FRAME ENOVIS", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 42000, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 12600, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 999.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 23100 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 21000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 18900 } ], "minimum": 999.6, "maximum": 23100 } ] }, { "description": "IMPLANT VIVIGEN BONE MATRIX LIFENET", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2440, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 732, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 2394, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1342 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1220 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1098 } ], "minimum": 732, "maximum": 2394 } ] }, { "description": "TRUELOK ELEVATE SYS STERILE ORTHOFIX", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 60000, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 18000, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 58.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 33000 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 30000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 27000 } ], "minimum": 58.8, "maximum": 33000 } ] }, { "description": "IMPLANT ALLOCELL AF MEDIUM BONE GRAFT VE", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6000, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1800, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 235.2, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3300 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2700 } ], "minimum": 235.2, "maximum": 3300 } ] }, { "description": "XTRAFIX 75MM PIN CLAMP 2-BAR", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5318.52, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1595.56, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 352.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2925.186 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2659.26 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2393.334 } ], "minimum": 352.8, "maximum": 2925.186 } ] }, { "description": "SWIVELOCK SP BC KL 4.75 ARTHREX", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1980, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 594, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 211.68, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1089 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 990 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 891 } ], "minimum": 211.68, "maximum": 1089 } ] }, { "description": "XTRAFIX 11 X 400MM BAR ZIMMER", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 973.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 292.14, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 594, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 535.59 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 486.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 438.21 } ], "minimum": 292.14, "maximum": 594 } ] }, { "description": "XTRAFIX 11 X 350MM BAR ZIMMER", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 923.88, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 277.16, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 3840, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 508.134 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 461.94 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 415.746 } ], "minimum": 277.16, "maximum": 3840 } ] }, { "description": "XTRAFIX 11 X 150MM BAR ZIMMER", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 724.12, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 217.24, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 112.37, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 398.266 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 362.06 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 325.854 } ], "minimum": 112.37, "maximum": 398.266 } ] }, { "description": "KYPHOPAK EXPRESS II TRAY", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11970, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 3591, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 9.79, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6583.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5985 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5386.5 } ], "minimum": 9.79, "maximum": 6583.5 } ] }, { "description": "IMPLANT SYNDEX CONSTRICTOR MEDLINE UNITE", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5200, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1560, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 4674, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2860 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2600 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2340 } ], "minimum": 1560, "maximum": 4674 } ] }, { "description": "IMPLANT HEMI VILEX", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8000, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 2400, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 940.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4400 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3600 } ], "minimum": 940.8, "maximum": 4400 } ] }, { "description": "IMPLANT SPONGE CHIPS 10CC 4-10MM TIDES", "code_information": [ { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4304, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1291.2, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1200, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2367.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2152 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1936.8 } ], "minimum": 1200, "maximum": 2367.2 } ] }, { "description": "GLUCOSE POC METER/TRUE METRIX", "code_information": [ { "code": "301", "type": "RC" }, { "code": "A9275", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.12, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1648.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.53 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.7 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.53 } ], "minimum": 10.53, "maximum": 1648.8 } ] }, { "description": "SURGERY EACH ADD 15 MIN", "code_information": [ { "code": "360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2275, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1080.625, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 545.4, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1023.75 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1137.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1023.75 } ], "minimum": 545.4, "maximum": 1137.5 } ] }, { "description": "SURG-PAIN PROC 1st 1/2 HOUR", "code_information": [ { "code": "360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6500, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3087.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 546, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3250 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2925 } ], "minimum": 546, "maximum": 3250 } ] }, { "description": "SURGERY 1st 1/2 HOUR", "code_information": [ { "code": "360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8450, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4013.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 13.46, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3802.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4225 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3802.5 } ], "minimum": 13.46, "maximum": 4225 } ] }, { "description": "SURG-CANCEL (PRIOR TO ANES)", "code_information": [ { "code": "360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5000, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2375, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 418.22, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2250 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2250 } ], "minimum": 418.22, "maximum": 2500 } ] }, { "description": "SURG-PAIN PROC EA ADDL 15 MIN", "code_information": [ { "code": "360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 831.25, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 5994, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 787.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 875 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 787.5 } ], "minimum": 787.5, "maximum": 5994 } ] }, { "description": "SURG-CANCEL (AFTER TO ANES)", "code_information": [ { "code": "360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6690, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3177.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 337.75, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3010.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3345 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3010.5 } ], "minimum": 337.75, "maximum": 3345 } ] }, { "description": "ANESTHESIA EA ADD MIN", "code_information": [ { "code": "370", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 45.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.6125, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 4644, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 20.475 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.475 } ], "minimum": 20.475, "maximum": 4644 } ] }, { "description": "ANESTHESIA FIRST 30 MINUTE", "code_information": [ { "code": "370", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1170, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 555.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 480, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 526.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 585 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 526.5 } ], "minimum": 480, "maximum": 585 } ] }, { "description": "SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION E", "code_information": [ { "code": "402", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 52098, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 30153.75 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24112 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 28129.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 31893.32 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 26048.63 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 32560.7875, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 26048.63, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 31518.8423, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 25527.6574, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 198, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 26048.63, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 41677.808, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 26680 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 26048.63 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 11320 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 57026, "10th_percentile": 57026, "90th_percentile": 57026, "count": "1 through 10" } ], "minimum": 198, "maximum": 41677.808 } ] }, { "description": "MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION", "code_information": [ { "code": "426", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 142811.68, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 78565.5 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 71405.84 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 74993.3886 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 85028.8218 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 71405.84 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 89257.3, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 71405.84, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 86401.0664, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 69977.7232, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1.2, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 71405.84, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114249.344, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 73137 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 71405.84 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 17364 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1.2, "maximum": 114249.344 } ] }, { "description": "MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION", "code_information": [ { "code": "427", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 93537.94, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 53270.25 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 46768.97 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 50848.2293 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 57652.6159 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 46768.97 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 58461.2125, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 46768.97, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 56590.4537, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 45833.5906, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 211.68, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 46768.97, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 74830.352, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 47903 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 46768.97 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 14267 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 211.68, "maximum": 74830.352 } ] }, { "description": "MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION", "code_information": [ { "code": "428", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 72849.34, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 41280.75 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 36424.67 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 39403.8519 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 44676.7797 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 36424.67 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 45530.8375, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 36424.67, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 44073.8507, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 35696.1766, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 300, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 36424.67, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 58279.472, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 37308 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 36424.67 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 10935 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 300, "maximum": 58279.472 } ] }, { "description": "COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHO", "code_information": [ { "code": "430", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 74729.54, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 41028.75 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 37364.77 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 39163.3095 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 44404.0485 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 37364.77 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 46705.9625, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 37364.77, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 45211.3717, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 36617.4746, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 6.66, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 37364.77, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 59783.632, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 38270 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 37364.77 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 57268 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 6.66, "maximum": 59783.632 } ] }, { "description": "MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC", "code_information": [ { "code": "448", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 54951.88, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 30626.25 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 27475.95 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 29233.7765 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 33145.7695 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 27475.95 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 34344.925, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 27475.94, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 33245.8874, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 26926.4212, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 56.7, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 27475.94, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 43961.504, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 28142 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 27475.94 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 43196 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 56.7, "maximum": 43961.504 } ] }, { "description": "SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC", "code_information": [ { "code": "451", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 41859.22, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 23145 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 20929.61 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 22092.674 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 25049.062 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 20929.61 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 26162.0125, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 20929.61, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 25324.8281, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 20511.0178, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 279.84, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 20929.61, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 33487.376, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 21437 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 20929.61 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 31009 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 279.84, "maximum": 33487.376 } ] }, { "description": "SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNA", "code_information": [ { "code": "457", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 77269.3, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 43045.5 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 38634.65 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 41088.3646 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 46586.7098 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 38634.65 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 48293.3125, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 38634.65, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 46747.9265, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 37861.957, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 44.1, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 38634.65, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 61815.44, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 39571 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 38634.65 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 50156 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 44.1, "maximum": 61815.44 } ] }, { "description": "BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC", "code_information": [ { "code": "462", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 34468.04, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19950 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17234.02 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 19261.06 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 21870.52 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17234.02 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21542.525, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17234.02, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20853.1642, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16889.3396, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 453.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17234.02, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 27574.432, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 17652 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17234.02 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 24732 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 453.6, "maximum": 27574.432 } ] }, { "description": "WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKEL", "code_information": [ { "code": "465", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 23631.32, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13020.75 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11815.66 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 12428.7399 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 14091.9237 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11815.66 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14769.575, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11815.66, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14296.9486, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11579.3468, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 379.2, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11815.66, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18905.056, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 12102 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11815.66 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 20834 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 379.2, "maximum": 20834 } ] }, { "description": "REVISION OF HIP OR KNEE REPLACEMENT WITH CC", "code_information": [ { "code": "467", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 45697.34, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 25689 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 22848.67 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 24521.0068 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 27802.3484 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 22848.67 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 28560.8375, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 22848.67, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 27646.8907, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 22391.6966, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 9.79, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 22848.67, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 36557.872, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 23403 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 22848.67 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 35723 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 9.79, "maximum": 36557.872 } ] }, { "description": "REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC", "code_information": [ { "code": "468", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 35608.34, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19674.75 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17804.17 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 18780.2047 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 21293.3261 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1784.17 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22255.2125, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17804.17, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21543.0457, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17448.0866, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 308.4, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17804.17, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 28486.672, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 18236 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17804.17 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 26008 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 308.4, "maximum": 28486.672 } ] }, { "description": "MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWE", "code_information": [ { "code": "470", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 24994.52, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14141.25 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12497.26 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 13498.2945 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 15304.6035 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12497.26 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15621.575, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12497.26, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15121.6846, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12247.3148, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 8.34, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12497.26, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19995.616, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 12800 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12497.26 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 18120 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 8.34, "maximum": 19995.616 } ] }, { "description": "CERVICAL SPINAL FUSION WITH MCC", "code_information": [ { "code": "471", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 62569.84, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 36215.25 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 31284.92 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 34964.62 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 39701.57 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 31284.92 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 39106.15, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 31284.92, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 37854.7532, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 30659.2216, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 32.41, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 31284.92, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 50055.872, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 32043 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 31284.92 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 33166 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 32.41, "maximum": 50055.872 } ] }, { "description": "CERVICAL SPINAL FUSION WITH CC", "code_information": [ { "code": "472", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 381615.3, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21729 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 19087.65 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 20741.0548 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 23516.5724 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 19087.65 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 23859.5625, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 19087.65, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 23096.0565, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18705.897, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 24, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 19087.65, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 30540.24, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 19550 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 19087.65 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 28085 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 24, "maximum": 30540.24 } ] }, { "description": "CERVICAL SPINAL FUSION WITHOUT CC/MCC", "code_information": [ { "code": "473", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 31634.14, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17755.5 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15817.07 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 16948.2166 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 19216.1858 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15817.07 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19771.3375, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15817.07, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19138.6547, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15500.7286, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 940.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15817.07, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 25307.312, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 16200 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15817.07 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 23481 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 27460.91, "10th_percentile": 27460.91, "90th_percentile": 27460.91, "count": "1 through 10" } ], "minimum": 940.8, "maximum": 25307.312 } ] }, { "description": "HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC", "code_information": [ { "code": "482", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 21134.34, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11898 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10567.17 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11357.0376 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12877.05231 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10567.17 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13208.9625, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10567.17, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12786.2757, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10355.8266, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1902, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10567.17, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16907.472, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 10823 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10567.17 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 16802 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1173.72, "maximum": 16907.472 } ] }, { "description": "MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMI", "code_information": [ { "code": "483", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 35918.02, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19111.5 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17959.01 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 18242.5638 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 20683.7394 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17959.01 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22448.7625, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17959.01, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21730.4021, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17599.8298, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 600, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17959.01, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 28734.416, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 18394 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17959.01 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 9258 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 600, "maximum": 28734.416 } ] }, { "description": "OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROC", "code_information": [ { "code": "516", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 26927.82, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15087.75 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13463.91 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 14401.7603 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 16328.9689 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13463.91 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16829.8875, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13463.91, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16291.3311, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13194.6318, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 904.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13463.91, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21542.256, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 13790 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13463.91 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 21214 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 904.8, "maximum": 21542.256 } ] }, { "description": "OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROC", "code_information": [ { "code": "517", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 19912.42, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11195.25 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9956.21 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 10686.2393 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12116.2459 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9956.21 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12445.2625, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9956.21, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12047.0141, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9757.0858, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 661.5, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9956.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15929.936, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 10198 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9956.21 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 18488 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 661.5, "maximum": 18488 } ] }, { "description": "BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC", "code_information": [ { "code": "519", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 25918.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14789.25 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12959.2 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 14116.8321 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 16005.9123 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12959.2 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16199, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12959.2, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15680.632, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12700.016, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 102, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12959.2, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20734.72, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 13273 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12959.2 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 20960 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 102, "maximum": 20960 } ] }, { "description": "MEDICAL BACK PROBLEMS WITHOUT MCC", "code_information": [ { "code": "552", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12456.44, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7209.75 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6228.22 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6960.77 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 7903.81 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6228.22 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7785, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6228.22, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7536.1462, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6103.6556, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 352.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6228.22, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9965.152, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6379 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6228.22 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6707 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 6328.74, "10th_percentile": 6328.74, "90th_percentile": 6328.74, "count": "1 through 10" } ], "minimum": 352.8, "maximum": 9965.152 } ] }, { "description": "SKIN ULCERS WITHOUT CC/MCC", "code_information": [ { "code": "594", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 11231.92, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6365.25 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5615.96 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6075.8433 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 693.3879 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5615.96 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7020, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5615.96, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6795.3116, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5503.6408, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 471.92, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5615.96, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8985.536, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5752 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5615.96 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 8907 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 471.92, "maximum": 8985.536 } ] }, { "description": "RECOVERY PACU EACH ADD 15 MIN", "code_information": [ { "code": "710", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1300, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 617.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 960, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 585 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 650 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 585 } ], "minimum": 585, "maximum": 960 } ] }, { "description": "RECOVERY RM INITIAL 1/2 HOUR", "code_information": [ { "code": "710", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4550, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2161.25, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 600, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2047.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2275 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2047.5 } ], "minimum": 600, "maximum": 2275 } ] }, { "description": "PACU INITIAL 30 MIN-ANC DEPTS", "code_information": [ { "code": "710", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4550, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2161.25, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1596, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2047.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2275 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2047.5 } ], "minimum": 1596, "maximum": 2275 } ] }, { "description": "POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC", "code_information": [ { "code": "857", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 27749.36, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16061.25 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13874.68 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 15506.6 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 17607.41 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13874.68 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17343, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13875, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16788.3628, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13597.1864, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1794, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13874.68, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22199.488, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14211 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13874.68 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 15665 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1173.72, "maximum": 22199.488 } ] }, { "description": "POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDU", "code_information": [ { "code": "858", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 18049.08, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9663 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9024.54 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 9223.6556 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 10457.9428 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9024.54 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11281, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9024.54, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10919.6934, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8844.0492, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1200, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9024.54, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14439.264, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 9243 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9024.54 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 13077 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1173.72, "maximum": 14439.264 } ] }, { "description": "COMPLICATIONS OF TREATMENT WITH CC", "code_information": [ { "code": "920", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 12987.72, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7619.25 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6493.86 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 7272.8281 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 8246.0603 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6493.86 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8117, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6493.86, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7857.5706, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6363.9828, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1740, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6493.86, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10390.176, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6651 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6493.86 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7383 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1173.72, "maximum": 10390.176 } ] }, { "description": "EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC", "code_information": [ { "code": "982", "type": "MS-DRG" } ], "standard_charges": [ { "setting": "inpatient", "discounted_cash": 31857, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18439 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15929 }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 17802 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 20214 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15928.5 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19911, "additional_payer_notes": "pays 125% of medicare" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15929, "additional_payer_notes": "pays 100% of medicare" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19273.485, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15609.93, "additional_payer_notes": "pays 98% of medicare" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "per diem", "standard_charge_dollar": 1173.72 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 234, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15928.5, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 25485.6, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 16315 }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15928.5 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 17907 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 234, "maximum": 25485.6 } ] }, { "description": "I&d abscess comp/multiple", "code_information": [ { "code": "10061", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 737.7412224, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 461.088264, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 310.18 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 327.369946 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 497.9753251, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 446.3334396, "additional_payer_notes": "pays 121% of medicare" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 361.493199, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 624, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 590.1929779, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 445.2336, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 399.53 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 310.18, "maximum": 624 } ] }, { "description": "Inc&rmvl fb subq tiss smpl", "code_information": [ { "code": "10120", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 737.7412224, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 461.088264, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 310.18 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 327.369946 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 497.9753251, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 446.3334396, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 361.493199, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 4964.54, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 590.1929779, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 445.2336, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 399.53 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 310.18, "maximum": 4964.54 } ] }, { "description": "I&d hmtma seroma/fluid collj", "code_information": [ { "code": "10140", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2997.309078, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1873.318174, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1332.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1406.36596 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2023.183628, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1813.371992, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1468.681448, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 504, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2397.847263, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1808.9232, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1620.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 2397.847263 } ] }, { "description": "Pnxr aspir absc hmtma bulla", "code_information": [ { "code": "10160", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 737.7412224, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 461.088264, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 310.18 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 327.369946 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 497.9753251, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 446.3334396, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 361.493199, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 42.84, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 590.1929779, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 445.2336, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 399.53 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 42.84, "maximum": 590.1929779 } ] }, { "description": "I&d complex po wound infctj", "code_information": [ { "code": "10180", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5271.460522, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3294.662826, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2251.18 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2375.934694 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3558.235852, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3189.233616, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2583.015656, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 81.9, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4217.168417, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3181.4034, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2862.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 81.9, "maximum": 4217.168417 } ] }, { "description": "Debride skin at fx site", "code_information": [ { "code": "11010", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1285.11423, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 803.196394, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 642.5571152, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 592.2 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 625.016246 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 642.5571152, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 867.4521055, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 642.5571152, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 777.4941094, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 629.7059729, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 371.7, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 642.5571152, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1028.091384, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 775.5818, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 642.5571152, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 703.59 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 371.7, "maximum": 1028.091384 } ] }, { "description": "Dbrdmt musc&/fsca 1st 20/<", "code_information": [ { "code": "11043", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1341.263706, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 838.289816, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 670.6318528, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 482.51 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 509.246692 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 670.6318528, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 905.3530013, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 670.6318528, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 811.4645419, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 657.2192157, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1248, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 670.6318528, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1073.010964, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 809.4702, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 670.6318528, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 612.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 1248 } ] }, { "description": "Dbrdmt bone 1st 20 sq cm/<", "code_information": [ { "code": "11044", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2997.309078, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1873.318174, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1332.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1406.36596 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2023.183628, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1813.371992, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1468.681448, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 9600, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2397.847263, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1808.9232, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1620.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 9600 } ] }, { "description": "Shave skin lesion >2.0 cm", "code_information": [ { "code": "11303", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 737.7412224, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 461.088264, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 310.18 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 327.369946 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 497.9753251, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 446.3334396, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 361.493199, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 157.5, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 590.1929779, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 445.2336, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 399.53 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 157.5, "maximum": 590.1929779 } ] }, { "description": "Exc tr-ext b9+marg 0.6-1 cm", "code_information": [ { "code": "11401", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 737.7412224, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 461.088264, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 310.18 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 327.369946 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 497.9753251, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 446.3334396, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 361.493199, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 279.84, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 590.1929779, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 445.2336, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 399.53 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 279.84, "maximum": 590.1929779 } ] }, { "description": "Exc tr-ext b9+marg 2.1-3cm", "code_information": [ { "code": "11403", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1285.11423, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 803.196394, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 642.5571152, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 592.2 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 625.016246 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 642.5571152, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 867.4521055, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 642.5571152, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 777.4941094, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 629.7059729, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 5520, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 642.5571152, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1028.091384, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 775.5818, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 642.5571152, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 703.59 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 5520 } ] }, { "description": "Exc tr-ext b9+marg >4.0 cm", "code_information": [ { "code": "11406", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2997.309078, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1873.318174, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1332.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1406.36596 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2023.183628, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1813.371992, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1468.681448, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 665.86, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2397.847263, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1808.9232, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1620.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 2397.847263 } ] }, { "description": "Exc h-f-nk-sp b9+marg 3.1-4", "code_information": [ { "code": "11424", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2997.309078, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1873.318174, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1332.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1406.36596 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2023.183628, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1813.371992, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1468.681448, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1194, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2397.847263, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1808.9232, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1620.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 2397.847263 } ] }, { "description": "Removal of nail plate", "code_information": [ { "code": "11730", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 364.1100736, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 227.568796, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 182.0550368, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 169.63 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 179.028358 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 182.0550368, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 245.7742997, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 182.0550368, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 220.2865945, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 178.4139361, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 3138, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 182.0550368, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 291.2880589, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 219.7454, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 182.0550368, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 198.7 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 169.63, "maximum": 3138 } ] }, { "description": "Removal of nail bed", "code_information": [ { "code": "11750", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 737.7412224, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 461.088264, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 310.18 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 327.369946 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 497.9753251, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 446.3334396, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 361.493199, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 210, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 590.1929779, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 445.2336, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 399.53 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 210, "maximum": 590.1929779 } ] }, { "description": "Intmd rpr face/mm 2.6-5.0 cm", "code_information": [ { "code": "12052", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 737.7412224, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 461.088264, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 310.18 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 327.369946 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 497.9753251, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 446.3334396, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 361.493199, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 840, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 590.1929779, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 445.2336, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 399.53 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 310.18, "maximum": 840 } ] }, { "description": "Cmplx rpr f/c/c/m/n/ax/g/h/f", "code_information": [ { "code": "13131", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 737.7412224, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 461.088264, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 310.18 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 327.369946 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 497.9753251, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 446.3334396, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 361.493199, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 221.76, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 590.1929779, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 445.2336, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 368.8706112, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 399.53 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 221.76, "maximum": 590.1929779 } ] }, { "description": "Tis trnfr f/c/c/m/n/a/g/h/f", "code_information": [ { "code": "14040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3744.42927, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2340.268294, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1575.36 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1662.659404 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2527.489758, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2265.379709, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1834.770342, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 74.18, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2995.543416, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2259.8114, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1829.23 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 74.18, "maximum": 2995.543416 } ] }, { "description": "Tis trnfr e/n/e/l 10 sq cm/<", "code_information": [ { "code": "14060", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3744.42927, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2340.268294, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1575.36 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1662.659404 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2527.489758, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2265.379709, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1834.770342, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1513.15, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2995.543416, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2259.8114, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1829.23 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 2995.543416 } ] }, { "description": "Splt agrft f/s/n/h/f/g/m 1st", "code_information": [ { "code": "15120", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6431.131034, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4019.456896, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3215.565517, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2890.35 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3050.531334 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3215.565517, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4341.013448, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3215.565517, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3890.834275, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3151.254206, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 157.31, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3215.565517, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5144.904827, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3881.2802, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3215.565517, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3660.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 157.31, "maximum": 5144.904827 } ] }, { "description": "Fth/gft fr n/e/e/l 20 sqcm/<", "code_information": [ { "code": "15260", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3744.42927, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2340.268294, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1575.36 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1662.659404 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2527.489758, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2265.379709, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1834.770342, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 202.25, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2995.543416, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2259.8114, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1829.23 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 202.25, "maximum": 2995.543416 } ] }, { "description": "Skin sub graft face/nk/hf/g", "code_information": [ { "code": "15275", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1341.263706, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 838.289816, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 670.6318528, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1575.36 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1662.659404 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 670.6318528, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 905.3530013, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 670.6318528, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 811.4645419, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 657.2192157, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 63, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 670.6318528, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1073.010964, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 809.4702, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 670.6318528, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1829.23 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 63, "maximum": 1829.23 } ] }, { "description": "Grfg autol soft tiss dir exc", "code_information": [ { "code": "15769", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6431.131034, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4019.456896, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3215.565517, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2890.35 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3050.531334 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3215.565517, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4341.013448, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3215.565517, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3890.834275, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3151.254206, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1740, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3215.565517, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5144.904827, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3881.2802, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3215.565517, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3660.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 5144.904827 } ] }, { "description": "Derma-fat-fascia graft", "code_information": [ { "code": "15770", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6431.131034, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4019.456896, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3215.565517, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2890.35 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3050.531334 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3215.565517, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4341.013448, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3215.565517, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3890.834275, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3151.254206, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 182.7, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3215.565517, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5144.904827, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3881.2802, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3215.565517, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3660.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 182.7, "maximum": 5144.904827 } ] }, { "description": "Blepharp upr eyelid xcsv skn", "code_information": [ { "code": "15823", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3744.42927, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2340.268294, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1575.36 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1662.659404 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2527.489758, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2265.379709, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1834.770342, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 48, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2995.543416, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2259.8114, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1829.23 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 48, "maximum": 2995.543416 } ] }, { "description": "Destruct b9 lesion 1-14", "code_information": [ { "code": "17110", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 364.1100736, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 227.568796, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 182.0550368, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 169.63 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 179.028358 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 182.0550368, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 245.7742997, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 182.0550368, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 220.2865945, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 178.4139361, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 150, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 182.0550368, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 291.2880589, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 219.7454, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 182.0550368, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 198.7 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 150, "maximum": 291.2880589 } ] }, { "description": "Destruct lesion 15 or more", "code_information": [ { "code": "17111", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 364.1100736, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 227.568796, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 182.0550368, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 169.63 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 179.028358 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 182.0550368, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 245.7742997, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 182.0550368, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 220.2865945, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 178.4139361, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 560.4, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 182.0550368, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 291.2880589, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 219.7454, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 182.0550368, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 198.7 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 169.63, "maximum": 560.4 } ] }, { "description": "Biopsy vrt bdy open thoracic", "code_information": [ { "code": "20250", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1.2, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1.2, "maximum": 4750.405471 } ] }, { "description": "Inj tendon sheath/ligament", "code_information": [ { "code": "20550", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 557.053952, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 348.15872, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 254.13 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 268.209542 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 376.0114176, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 337.017641, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 272.9564365, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 624, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 445.6431616, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 336.189, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 295.19 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 254.13, "maximum": 624 } ] }, { "description": "Inj trigger point 1/2 muscl", "code_information": [ { "code": "20552", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 557.053952, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 348.15872, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 254.13 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 268.209542 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 376.0114176, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 337.017641, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 272.9564365, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 2634, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 445.6431616, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 336.189, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 295.19 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 254.13, "maximum": 2634 } ] }, { "description": "Inject trigger points 3/>", "code_information": [ { "code": "20553", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 557.053952, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 348.15872, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 254.13 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 268.209542 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 376.0114176, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 337.017641, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 272.9564365, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 196.46, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 445.6431616, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 336.189, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 295.19 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 196.46, "maximum": 445.6431616 } ] }, { "description": "Drain/inj joint/bursa w/o us", "code_information": [ { "code": "20605", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 557.053952, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 348.15872, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 254.13 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 268.209542 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 376.0114176, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 337.017641, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 272.9564365, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 126, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 445.6431616, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 336.189, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 295.19 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 126, "maximum": 445.6431616 } ] }, { "description": "Drain/inj joint/bursa w/o us", "code_information": [ { "code": "20610", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 557.053952, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 348.15872, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 254.13 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 268.209542 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 376.0114176, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 337.017641, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 272.9564365, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1883.7, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 445.6431616, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 336.189, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 295.19 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 254.13, "maximum": 1883.7 } ] }, { "description": "Removal of implant deep", "code_information": [ { "code": "20680", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5271.460522, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3294.662826, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2251.18 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2375.934694 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3558.235852, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3189.233616, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2583.015656, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 524.36, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4217.168417, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3181.4034, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2862.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 524.36, "maximum": 4217.168417 } ] }, { "description": "Appl unipln uni ext fixj sys", "code_information": [ { "code": "20690", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1800, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 10534.82813 } ] }, { "description": "Appl mltpln uni ext fixj sys", "code_information": [ { "code": "20692", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23299.56312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14562.22695, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15727.20511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14096.23569, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11416.78593, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 88.75, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18639.6505, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14061.6182, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12866.82 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 88.75, "maximum": 18639.6505 } ] }, { "description": "Rmvl ext fixj sys under anes", "code_information": [ { "code": "20694", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.353, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.353, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.353, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.353, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 44.16, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 44.16, "maximum": 2334.539218 } ] }, { "description": "Removal of bone for graft", "code_information": [ { "code": "20900", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 10534.82813 } ] }, { "description": "Removal of bone for graft", "code_information": [ { "code": "20902", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 2880, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 10534.82813 } ] }, { "description": "Remove cartilage for graft", "code_information": [ { "code": "20910", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1341.263706, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 838.289816, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 670.6318528, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 482.51 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 509.246692 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 670.6318528, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 905.3530013, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 670.6318528, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 811.4645419, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 657.2192157, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1494, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 670.6318528, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1073.010964, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 809.4702, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 670.6318528, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 612.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 482.51, "maximum": 1494 } ] }, { "description": "Remove cartilage for graft", "code_information": [ { "code": "20912", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6431.131034, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4019.456896, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3215.565517, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2890.35 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3050.531334 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3215.565517, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4341.013448, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3215.565517, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3890.834275, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3151.254206, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 5584.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3215.565517, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5144.904827, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3881.2802, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3215.565517, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3660.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 5584.8 } ] }, { "description": "Sp bone algrft morsel add-on", "code_information": [ { "code": "20930", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "median_amount": 1000, "10th_percentile": 1000, "90th_percentile": 1000, "count": "1 through 10", "additional_payer_notes": "paid via surg time charge" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 300, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "median_amount": 3203.57, "10th_percentile": 1859.47, "90th_percentile": 3500.71, "count": "1 through 10" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 0.01, "maximum": 359.35 } ] }, { "description": "Sp bone algrft struct add-on", "code_information": [ { "code": "20931", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "paid via surg time charge" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 2696.47, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 0.01, "maximum": 2696.47 } ] }, { "description": "osteoarticular allograft add-on", "code_information": [ { "code": "20932", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "paid via surg time charge" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 2316, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 0.01, "maximum": 2316 } ] }, { "description": "Sp bone agrft local add-on", "code_information": [ { "code": "20936", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "median_amount": 1000, "10th_percentile": 1000, "90th_percentile": 1000, "count": "1 through 10", "additional_payer_notes": "paid via surg time charge" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 3138, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "median_amount": 3203.57, "10th_percentile": 1859.47, "90th_percentile": 3500.71, "count": "1 through 10" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 4533.75, "10th_percentile": 4533.75, "90th_percentile": 4533.75, "count": "1 through 10" } ], "minimum": 0.01, "maximum": 3138 } ] }, { "description": "Exc face les sbq 2 cm/>", "code_information": [ { "code": "21012", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2997.309078, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1873.318174, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1332.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1406.36596 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2023.183628, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1813.371992, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1468.681448, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 12600, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2397.847263, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1808.9232, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1620.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 12600 } ] }, { "description": "Exc face tum deep 2 cm/>", "code_information": [ { "code": "21014", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5271.460522, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3294.662826, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2251.18 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2375.934694 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3558.235852, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3189.233616, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2583.015656, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 732, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4217.168417, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3181.4034, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2862.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 4217.168417 } ] }, { "description": "Clsd tx nsl fx w/mnpj&stablj", "code_information": [ { "code": "21320", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6016.875446, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3760.547154, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2542.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2683.724534 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4061.390926, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3640.209645, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2948.268969, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1752, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4813.500357, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3631.2724, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3243.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 4813.500357 } ] }, { "description": "Exc neck les sc 3 cm/>", "code_information": [ { "code": "21552", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5271.460522, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3294.662826, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2251.18 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2375.934694 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3558.235852, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3189.233616, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2583.015656, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 2334, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4217.168417, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3181.4034, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2862.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 4217.168417 } ] }, { "description": "Exc neck les sc < 3 cm", "code_information": [ { "code": "21555", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2997.309078, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1873.318174, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1332.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1406.36596 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2023.183628, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1813.371992, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1468.681448, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 18000, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2397.847263, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1808.9232, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1620.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 18000 } ] }, { "description": "Exc back les sc < 3 cm", "code_information": [ { "code": "21930", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2997.309078, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1873.318174, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1332.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1406.36596 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2023.183628, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1813.371992, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1468.681448, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1800, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2397.847263, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1808.9232, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1620.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 2397.847263 } ] }, { "description": "Exc back les sc 3 cm/>", "code_information": [ { "code": "21931", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2997.309078, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1873.318174, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1332.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1406.36596 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2023.183628, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1813.371992, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1468.681448, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1595.56, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2397.847263, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1808.9232, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1620.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 2397.847263 } ] }, { "description": "Perq cervicothoracic inject", "code_information": [ { "code": "22510", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 594, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 4750.405471 } ] }, { "description": "Perq lumbosacral injection", "code_information": [ { "code": "22511", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 292.14, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 292.14, "maximum": 4750.405471 } ] }, { "description": "Vertebroplasty addl inject", "code_information": [ { "code": "22512", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 480, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 0.01, "maximum": 480 } ] }, { "description": "Perq vertebral augmentation", "code_information": [ { "code": "22513", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 277.16, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 277.16, "maximum": 10534.82813 } ] }, { "description": "Perq vertebral augmentation", "code_information": [ { "code": "22514", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 217.24, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 217.24, "maximum": 10534.82813 } ] }, { "description": "Perq vertebral augmentation", "code_information": [ { "code": "22515", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 3591, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 0.01, "maximum": 3591 } ] }, { "description": "Arthrd ant ntrbdy cervical", "code_information": [ { "code": "22551", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23299.56312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14562.22695, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15727.20511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14096.23569, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11416.78593, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "median_amount": 1000, "10th_percentile": 1000, "90th_percentile": 1000, "count": "1 through 10", "additional_payer_notes": "paid via surg time charge" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1560, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18639.6505, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14061.6182, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12866.82 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "median_amount": 3203.57, "10th_percentile": 1859.47, "90th_percentile": 3500.71, "count": "1 through 10" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1444.88, "maximum": 18639.6505 } ] }, { "description": "Arthrd ant ntrbd cervical ea", "code_information": [ { "code": "22552", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "median_amount": 1000, "10th_percentile": 1000, "90th_percentile": 1000, "count": "1 through 10", "additional_payer_notes": "paid via surg time charge" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 2400, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "median_amount": 2363.51, "10th_percentile": 1691.45, "90th_percentile": 3035.56, "count": "1 through 10" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 0.01, "maximum": 2400 } ] }, { "description": "Arthrd ant ntrbd min dsc crv", "code_information": [ { "code": "22554", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23299.56312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14562.22695, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15727.20511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14096.23569, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11416.78593, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1883.7, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18639.6505, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14061.6182, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12866.82 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1444.88, "maximum": 18639.6505 } ] }, { "description": "Arthrd ant ntrbd min dsc lum", "code_information": [ { "code": "22558", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 49242.66343, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 30776.66465, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24621.33, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 12038.76 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24621.33172, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 33238.79782, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24621.33172, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 29791.81138, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24128.90508, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 36.44, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24621.33172, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 39394.13075, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 29718.6372, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24621.33172, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 50156 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 36.44, "maximum": 50156 } ] }, { "description": "Arthrd pst tq 1ntrspc crv", "code_information": [ { "code": "22600", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 31820.27, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19887.66762, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 12038.76 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21478.68103, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19251.26225, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15591.93141, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "other", "standard_charge_dollar": 1291.2, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 25456.21455, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 19203.982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 28085 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1291.2, "maximum": 28085 } ] }, { "description": "Arthrd pst tq 1ntrspc lumbar", "code_information": [ { "code": "22612", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 31820.26819, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19887.66762, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21478.68103, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19251.26225, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15591.93141, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 44916.6, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 25456.21455, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 19203.982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 18390.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 11553.21, "maximum": 44916.6 } ] }, { "description": "Arthrd pst tq 1ntrspc ea add", "code_information": [ { "code": "22614", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 0.01, "maximum": 0.010246 } ] }, { "description": "Arthrd pst tq 1ntrspc lum", "code_information": [ { "code": "22630", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 49242.66343, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 30776.66465, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24621.33172, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24621.33172, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 33238.79782, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24621.33172, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 29791.81138, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24128.90508, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 44916.6, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24621.33172, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 39394.13075, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 29718.6372, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24621.33172, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 18390.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 11553.21, "maximum": 44916.6 } ] }, { "description": "Arthrd cmbn 1ntrspc lumbar", "code_information": [ { "code": "22633", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 49242.66343, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 30776.66465, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24621.33172, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24621.33172, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 33238.79782, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24621.33172, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 29791.81138, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24128.90508, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 44916.6, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24621.33172, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 39394.13075, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 29718.6372, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24621.33172, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 18390.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 4533.75, "10th_percentile": 4533.75, "90th_percentile": 4533.75, "count": "1 through 10" } ], "minimum": 11553.21, "maximum": 44916.6 } ] }, { "description": "Arthrd cmbn 1ntrspc ea addl", "code_information": [ { "code": "22634", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 0.01, "maximum": 0.010246 } ] }, { "description": "Exploration of spinal fusion", "code_information": [ { "code": "22830", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476 }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.27, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 12038.76 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 20386.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 50156 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 6452.582229, "maximum": 50156 } ] }, { "description": "Insert spine fixation device", "code_information": [ { "code": "22840", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 4533.75, "10th_percentile": 4533.75, "90th_percentile": 4533.75, "count": "1 through 10" } ], "minimum": 0.01, "maximum": 0.010246 } ] }, { "description": "Insert spine fixation device", "code_information": [ { "code": "22842", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 0.01, "maximum": 0.010246 } ] }, { "description": "Insert spine fixation device", "code_information": [ { "code": "22845", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 0.01, "maximum": 0.010246 } ] }, { "description": "Insj biomechanical device", "code_information": [ { "code": "22853", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "median_amount": 1000, "10th_percentile": 1000, "90th_percentile": 1000, "count": "1 through 10", "additional_payer_notes": "paid via surg time charge" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "median_amount": 3203.57, "10th_percentile": 3203.57, "90th_percentile": 3500.71, "count": "1 through 10" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 4533.75, "10th_percentile": 4533.75, "90th_percentile": 4533.75, "count": "1 through 10" } ], "minimum": 0.01, "maximum": 0.010246 } ] }, { "description": "Insj biomechanical device", "code_information": [ { "code": "22854", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 0.01, "maximum": 0.010246 } ] }, { "description": "Tot disc arthrp 1ntrspc crv", "code_information": [ { "code": "22856", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 31820.26819, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19887.66762, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 15480.45 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 16338.35357 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21478.68103, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19251.26225, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15591.93141, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 44916.59, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 25456.21455, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 19203.982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 18390.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "median_amount": 3575, "10th_percentile": 3575, "90th_percentile": 3575, "count": "1 through 10" }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 15480.45, "maximum": 44916.59 } ] }, { "description": "Exc abdl tum deep 5 cm/>", "code_information": [ { "code": "22901", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5271.460522, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3294.662826, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2251.18 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2375.934694 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3558.235852, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3189.233616, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2583.015656, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6990.39, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4217.168417, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3181.4034, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2862.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 6990.39 } ] }, { "description": "Exploratory shoulder surgery", "code_information": [ { "code": "23040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Exc shoulder les sc 3 cm/>", "code_information": [ { "code": "23071", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2997.309078, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1873.318174, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1332.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1406.36596 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2023.183628, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1813.371992, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1468.681448, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3957.34, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2397.847263, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1808.9232, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1620.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 3957.34 } ] }, { "description": "Injection for shoulder x-ray", "code_information": [ { "code": "23350", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 370.7, "maximum": 391.24351 } ] }, { "description": "Reconstruct shoulder joint", "code_information": [ { "code": "23472", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 31820.26819, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19887.66762, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21478.68103, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19251.26225, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15591.93141, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 44916.59, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 25456.21455, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 19203.982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 18390.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 11553.21, "maximum": 44916.59 } ] }, { "description": "Revis reconst shoulder joint", "code_information": [ { "code": "23473", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23299.56312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14562.22695, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15727.20511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14096.23569, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11416.78593, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 31426.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18639.6505, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14061.6182, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12866.82 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1073.67, "maximum": 31426.44 } ] }, { "description": "Optx prox humrl fx w/int fix", "code_information": [ { "code": "23615", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23299.56312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14562.22695, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15727.20511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14096.23569, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11416.78593, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 31426.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18639.6505, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14061.6182, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12866.82 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 31426.44 } ] }, { "description": "Cltx sho dslc w/mnpj w/anes", "code_information": [ { "code": "23655", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 3908.91 } ] }, { "description": "Mnpj anes sho jt fixj aprats", "code_information": [ { "code": "23700", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 3908.91 } ] }, { "description": "Arthrt elbw expl drg/rmvl fb", "code_information": [ { "code": "24000", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 7924.77 } ] }, { "description": "Ex arm/elbow tum deep 5 cm/>", "code_information": [ { "code": "24073", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5271.460522, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3294.662826, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2251.18 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2375.934694 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3558.235852, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3189.233616, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2583.015656, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6990.39, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4217.168417, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3181.4034, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2862.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 6990.39 } ] }, { "description": "Excision olecranon bursa", "code_information": [ { "code": "24105", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Rpr tdn/musc upr a/e each", "code_information": [ { "code": "24341", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Repair of ruptured tendon", "code_information": [ { "code": "24342", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Reconstruct elbow lat ligmnt", "code_information": [ { "code": "24344", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 5807.28, "maximum": 17448.13 } ] }, { "description": "Reconstruct elbow med ligmnt", "code_information": [ { "code": "24346", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23299.56312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14562.22695, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15727.20511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14096.23569, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11416.78593, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 31426.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18639.6505, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14061.6182, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12866.82 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 11416.78593, "maximum": 31426.44 } ] }, { "description": "Repair elbow w/deb open", "code_information": [ { "code": "24358", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 2657.52, "maximum": 7924.77 } ] }, { "description": "Repair elbow deb/attch open", "code_information": [ { "code": "24359", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 2657.52, "maximum": 7924.77 } ] }, { "description": "Repair humerus with graft", "code_information": [ { "code": "24435", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23299.56312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14562.22695, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15727.20511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14096.23569, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11416.78593, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 31426.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18639.6505, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14061.6182, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12866.82 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 31426.44 } ] }, { "description": "Treat humerus fracture", "code_information": [ { "code": "24515", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23299.56312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14562.22695, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15727.20511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14096.23569, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11416.78593, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 31426.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18639.6505, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14061.6182, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12866.82 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 31426.44 } ] }, { "description": "Treat elbow fracture", "code_information": [ { "code": "24635", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Treat radius fracture", "code_information": [ { "code": "24665", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 17448.13 } ] }, { "description": "Treat ulnar fracture", "code_information": [ { "code": "24685", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Incision of tendon sheath", "code_information": [ { "code": "25000", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 3908.91 } ] }, { "description": "Remove wrist tendon lesion", "code_information": [ { "code": "25111", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 3908.91 } ] }, { "description": "Excise wrist tendon sheath", "code_information": [ { "code": "25118", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 3908.91 } ] }, { "description": "Removal of wrist bone", "code_information": [ { "code": "25210", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Transplant forearm tendon", "code_information": [ { "code": "25310", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Arthrp ntrcrp/crp/mtcr ntrps", "code_information": [ { "code": "25447", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 2657.52, "maximum": 7924.77 } ] }, { "description": "Optx radial shaft fracture", "code_information": [ { "code": "25515", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Optx ulnar shft fx int fixj", "code_information": [ { "code": "25545", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Optx rdl&uln shft fx rds&uln", "code_information": [ { "code": "25575", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Cltx dst rdl fx/ephys sep w/", "code_information": [ { "code": "25605", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 3908.91 } ] }, { "description": "Optx dst rd xartc fx/epi sep", "code_information": [ { "code": "25607", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 773.72, "maximum": 17448.13 } ] }, { "description": "Optx dst rd xart fx/epi sep2", "code_information": [ { "code": "25608", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 773.72, "maximum": 17448.13 } ] }, { "description": "Optx dst rd xart fx/ep sep3+", "code_information": [ { "code": "25609", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 773.72, "maximum": 17448.13 } ] }, { "description": "Arthrd wrist with autograft", "code_information": [ { "code": "25825", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 773.72, "maximum": 17448.13 } ] }, { "description": "Treat hand bone lesion", "code_information": [ { "code": "26034", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 3908.91 } ] }, { "description": "Incise finger tendon sheath", "code_information": [ { "code": "26055", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 3908.91 } ] }, { "description": "Explore/treat hand joint", "code_information": [ { "code": "26070", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 3908.91 } ] }, { "description": "Biopsy finger joint lining", "code_information": [ { "code": "26110", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 3908.91 } ] }, { "description": "Exc hand les sc 1.5 cm/>", "code_information": [ { "code": "26111", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2997.309078, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1873.318174, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1332.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1406.36596 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2023.183628, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1813.371992, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1468.681448, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3957.34, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2397.847263, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1808.9232, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1620.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 3957.34 } ] }, { "description": "Exc hand les sc < 1.5 cm", "code_information": [ { "code": "26115", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2997.309078, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1873.318174, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1332.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1406.36596 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2023.183628, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1813.371992, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1468.681448, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3957.34, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2397.847263, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1808.9232, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1620.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 3957.34 } ] }, { "description": "Exc hand tum deep < 1.5 cm", "code_information": [ { "code": "26116", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2997.309078, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1873.318174, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1332.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1406.36596 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2023.183628, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1813.371992, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1468.681448, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3957.34, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2397.847263, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1808.9232, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1620.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 3957.34 } ] }, { "description": "Remove tendon sheath lesion", "code_information": [ { "code": "26160", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 3908.91 } ] }, { "description": "Partial removal finger bone", "code_information": [ { "code": "26236", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 3908.91 } ] }, { "description": "Repair hand tendon", "code_information": [ { "code": "26410", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 3908.91 } ] }, { "description": "Repair/graft hand tendon", "code_information": [ { "code": "26412", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Repair finger tendon", "code_information": [ { "code": "26418", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 3908.91 } ] }, { "description": "Repair/graft finger tendon", "code_information": [ { "code": "26420", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 7924.77 } ] }, { "description": "Repair finger/hand tendon", "code_information": [ { "code": "26426", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Realignment of tendons", "code_information": [ { "code": "26437", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Transplant/graft hand tendon", "code_information": [ { "code": "26483", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Repair hand joint with graft", "code_information": [ { "code": "26541", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 2657.52, "maximum": 7924.77 } ] }, { "description": "Repair nonunion hand", "code_information": [ { "code": "26546", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 17448.13 } ] }, { "description": "Treat metacarpal fracture", "code_information": [ { "code": "26615", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 7924.77 } ] }, { "description": "Treat finger fracture each", "code_information": [ { "code": "26746", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 773.72, "maximum": 7924.77 } ] }, { "description": "Fusion of finger joint", "code_information": [ { "code": "26860", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Amputation of finger/thumb", "code_information": [ { "code": "26951", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 7924.77 } ] }, { "description": "Drainage of pelvis lesion", "code_information": [ { "code": "26990", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 7924.77 } ] }, { "description": "Injection for hip x-ray", "code_information": [ { "code": "27095", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 391.24351 } ] }, { "description": "Inject sacroiliac joint", "code_information": [ { "code": "27096", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 606.8 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 640.42623 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "median_amount": 2700, "10th_percentile": 2700, "90th_percentile": 2700, "count": "1 through 10", "additional_payer_notes": "paid via surg time charge" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 890.29 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 890.29 } ] }, { "description": "Total hip arthroplasty", "code_information": [ { "code": "27130", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23299.56312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14562.22695, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15727.20511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14096.23569, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11416.78593, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 31426.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18639.6505, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14061.6182, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12866.82 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 11416.78593, "maximum": 31426.44 } ] }, { "description": "Arthrd si jt perq/min nvas", "code_information": [ { "code": "27279", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 31820.26819, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19887.66762, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 15480.45 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 16338.35357 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21478.68103, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19251.26225, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15591.93141, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 44916.59, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 25456.21455, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 19203.982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15910.13409, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 18390.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1444.88, "maximum": 44916.59 } ] }, { "description": "Exploration of knee joint", "code_information": [ { "code": "27310", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 7924.77 } ] }, { "description": "Exc thigh/knee les sc < 3 cm", "code_information": [ { "code": "27327", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2997.309078, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1873.318174, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1332.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1406.36596 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2023.183628, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1813.371992, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1468.681448, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3957.34, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2397.847263, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1808.9232, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1620.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 3957.34 } ] }, { "description": "Exc thigh/knee tum deep <5cm", "code_information": [ { "code": "27328", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5271.460522, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3294.662826, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2251.18 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2375.934694 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3558.235852, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3189.233616, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2583.015656, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6990.39, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4217.168417, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3181.4034, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2862.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 6990.39 } ] }, { "description": "Removal of knee cyst", "code_information": [ { "code": "27345", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 7924.77 } ] }, { "description": "Remove knee cyst", "code_information": [ { "code": "27347", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 7924.77 } ] }, { "description": "Repair of kneecap tendon", "code_information": [ { "code": "27380", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 17448.13 } ] }, { "description": "Repair/graft kneecap tendon", "code_information": [ { "code": "27381", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Repair of thigh muscle", "code_information": [ { "code": "27385", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Revision of unstable kneecap", "code_information": [ { "code": "27420", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Revision of unstable kneecap", "code_information": [ { "code": "27422", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1073.67, "maximum": 17448.13 } ] }, { "description": "Reconstruction knee", "code_information": [ { "code": "27427", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Revise kneecap with implant", "code_information": [ { "code": "27438", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23299.56312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14562.22695, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15727.20511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14096.23569, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11416.78593, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 31426.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18639.6505, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14061.6182, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12866.82 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 773.72, "maximum": 31426.44 } ] }, { "description": "Revision of knee joint", "code_information": [ { "code": "27446", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23299.56312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14562.22695, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15727.20511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14096.23569, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11416.78593, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 31426.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18639.6505, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14061.6182, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12866.82 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 11416.78593, "maximum": 31426.44 } ] }, { "description": "Total knee arthroplasty", "code_information": [ { "code": "27447", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23299.56312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14562.22695, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15727.20511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14096.23569, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11416.78593, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 31426.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18639.6505, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14061.6182, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12866.82 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 11416.78593, "maximum": 31426.44 } ] }, { "description": "Treatment of thigh fracture", "code_information": [ { "code": "27509", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Treat knee fracture", "code_information": [ { "code": "27535", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.27, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6051.34 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 20386.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 16431 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 6051.34, "maximum": 20386.8 } ] }, { "description": "Fixation of knee joint", "code_information": [ { "code": "27570", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 3908.91 } ] }, { "description": "Decompression of lower leg", "code_information": [ { "code": "27600", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Incision of achilles tendon", "code_information": [ { "code": "27605", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 3908.91 } ] }, { "description": "Exploration of ankle joint", "code_information": [ { "code": "27612", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Exc leg/ankle tum < 3 cm", "code_information": [ { "code": "27618", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2997.309078, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1873.318174, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1332.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1406.36596 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2023.183628, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1813.371992, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1468.681448, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3957.34, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2397.847263, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1808.9232, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1620.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 3957.34 } ] }, { "description": "Remove ankle joint lining", "code_information": [ { "code": "27626", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 7924.77 } ] }, { "description": "Removal of tendon lesion", "code_information": [ { "code": "27630", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Exc leg/ankle les sc 3 cm/>", "code_information": [ { "code": "27632", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5271.460522, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3294.662826, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2251.18 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2375.934694 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3558.235852, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3189.233616, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2583.015656, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6990.39, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4217.168417, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3181.4034, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2862.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 6990.39 } ] }, { "description": "Remove lower leg bone lesion", "code_information": [ { "code": "27635", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Partial removal of tibia", "code_information": [ { "code": "27640", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 7924.77 } ] }, { "description": "Repair achilles tendon", "code_information": [ { "code": "27650", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Repair/graft achilles tendon", "code_information": [ { "code": "27652", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Repair of achilles tendon", "code_information": [ { "code": "27654", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Repair of leg tendon each", "code_information": [ { "code": "27658", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 7924.77 } ] }, { "description": "Repair of leg tendon each", "code_information": [ { "code": "27659", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 17448.13 } ] }, { "description": "Repair lower leg tendons", "code_information": [ { "code": "27676", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Release of lower leg tendon", "code_information": [ { "code": "27680", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Revision of lower leg tendon", "code_information": [ { "code": "27685", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Revision of calf tendon", "code_information": [ { "code": "27687", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Revise lower leg tendon", "code_information": [ { "code": "27690", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 17448.13 } ] }, { "description": "Revise lower leg tendon", "code_information": [ { "code": "27691", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 17448.13 } ] }, { "description": "Repair of ankle ligament", "code_information": [ { "code": "27695", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 17448.13 } ] }, { "description": "Repair of ankle ligament", "code_information": [ { "code": "27698", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 17448.13 } ] }, { "description": "Revision of ankle joint", "code_information": [ { "code": "27700", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 773.72, "maximum": 17448.13 } ] }, { "description": "Osteotomy tibia", "code_information": [ { "code": "27705", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 17448.13 } ] }, { "description": "Osteotomy fibula", "code_information": [ { "code": "27707", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 7924.77 } ] }, { "description": "Osteotomy tibia & fibula", "code_information": [ { "code": "27709", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23299.56312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14562.22695, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15727.20511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14096.23569, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11416.78593, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 31426.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18639.6505, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14061.6182, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12866.82 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 31426.44 } ] }, { "description": "Treatment of tibia fracture", "code_information": [ { "code": "27759", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23299.56312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14562.22695, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15727.20511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14096.23569, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11416.78593, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 31426.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18639.6505, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14061.6182, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12866.82 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 31426.44 } ] }, { "description": "Treatment of fibula fracture", "code_information": [ { "code": "27784", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Treatment of ankle fracture", "code_information": [ { "code": "27792", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Treatment of ankle fracture", "code_information": [ { "code": "27814", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Treatment of ankle fracture", "code_information": [ { "code": "27822", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Treatment of ankle fracture", "code_information": [ { "code": "27823", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Treat lower leg fracture", "code_information": [ { "code": "27825", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 3908.91 } ] }, { "description": "Treat lower leg fracture", "code_information": [ { "code": "27828", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23299.56312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14562.22695, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15727.20511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14096.23569, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11416.78593, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 31426.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18639.6505, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14061.6182, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12866.82 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 31426.44 } ] }, { "description": "Treat lower leg joint", "code_information": [ { "code": "27829", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 17448.13 } ] }, { "description": "Fusion of ankle joint open", "code_information": [ { "code": "27870", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23299.56312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14562.22695, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15727.20511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14096.23569, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11416.78593, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 31426.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18639.6505, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14061.6182, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12866.82 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 31426.44 } ] }, { "description": "Treatment of foot infection", "code_information": [ { "code": "28003", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Incision of foot fascia", "code_information": [ { "code": "28008", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Incision of toe tendon", "code_information": [ { "code": "28010", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1315.81, "maximum": 3908.91 } ] }, { "description": "Exploration of foot joint", "code_information": [ { "code": "28022", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 7924.77 } ] }, { "description": "Decompression of tibia nerve", "code_information": [ { "code": "28035", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3543.793926, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2214.871204, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1669.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1761.64601 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2392.0609, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2143.995325, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1736.459024, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4769.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2835.035141, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2138.7324, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1952.77 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 4769.52 } ] }, { "description": "Exc foot/toe tum sc 1.5 cm/>", "code_information": [ { "code": "28039", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5271.460522, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3294.662826, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2251.18 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2375.934694 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3558.235852, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3189.233616, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2583.015656, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6990.39, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4217.168417, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3181.4034, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2862.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 6990.39 } ] }, { "description": "Exc foot/toe tum dep 1.5cm/>", "code_information": [ { "code": "28041", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5271.460522, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3294.662826, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2251.18 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2375.934694 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3558.235852, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3189.233616, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2583.015656, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6990.39, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4217.168417, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3181.4034, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2862.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 6990.39 } ] }, { "description": "Exc foot/toe tum deep <1.5cm", "code_information": [ { "code": "28045", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5271.460522, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3294.662826, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2251.18 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2375.934694 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3558.235852, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3189.233616, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2583.015656, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6990.39, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4217.168417, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3181.4034, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2635.730261, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2862.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 6990.39 } ] }, { "description": "Neurectomy foot", "code_information": [ { "code": "28055", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3543.793926, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2214.871204, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1669.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1761.64601 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2392.0609, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2143.995325, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1736.459024, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4769.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2835.035141, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2138.7324, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1952.77 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1669.14, "maximum": 4769.52 } ] }, { "description": "Partial removal foot fascia", "code_information": [ { "code": "28060", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 7924.77 } ] }, { "description": "Removal of foot fascia", "code_information": [ { "code": "28062", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Removal of foot joint lining", "code_information": [ { "code": "28070", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Removal of foot joint lining", "code_information": [ { "code": "28072", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Removal of foot lesion", "code_information": [ { "code": "28080", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 3908.91 } ] }, { "description": "Excise foot tendon sheath", "code_information": [ { "code": "28086", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 7924.77 } ] }, { "description": "Excise foot tendon sheath", "code_information": [ { "code": "28088", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 7924.77 } ] }, { "description": "Removal of foot lesion", "code_information": [ { "code": "28090", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 3908.91 } ] }, { "description": "Removal of toe lesions", "code_information": [ { "code": "28092", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 3908.91 } ] }, { "description": "Removal of foot lesion", "code_information": [ { "code": "28104", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 7924.77 } ] }, { "description": "Part removal of metatarsal", "code_information": [ { "code": "28110", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Part removal of metatarsal", "code_information": [ { "code": "28111", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Part removal of metatarsal", "code_information": [ { "code": "28112", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Part removal of metatarsal", "code_information": [ { "code": "28113", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Revision of foot", "code_information": [ { "code": "28116", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Removal of heel bone", "code_information": [ { "code": "28118", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 7924.77 } ] }, { "description": "Part removal of ankle/heel", "code_information": [ { "code": "28120", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1073.67, "maximum": 7924.77 } ] }, { "description": "Partial removal of foot bone", "code_information": [ { "code": "28122", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Partial removal of toe", "code_information": [ { "code": "28124", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Partial removal of toe", "code_information": [ { "code": "28153", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Removal of foot foreign body", "code_information": [ { "code": "28192", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2997.309078, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1873.318174, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1332.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1406.36596 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2023.183628, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1813.371992, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1468.681448, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3957.34, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2397.847263, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1808.9232, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1620.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 3957.34 } ] }, { "description": "Removal of foot foreign body", "code_information": [ { "code": "28193", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2997.309078, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1873.318174, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1332.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1406.36596 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2023.183628, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1813.371992, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1468.681448, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3957.34, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2397.847263, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1808.9232, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1498.654539, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1620.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 3957.34 } ] }, { "description": "Repair of foot tendon", "code_information": [ { "code": "28200", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Repair of foot tendon", "code_information": [ { "code": "28208", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Release of foot tendon", "code_information": [ { "code": "28225", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 7924.77 } ] }, { "description": "Incision of foot tendon(s)", "code_information": [ { "code": "28230", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 3908.91 } ] }, { "description": "Incision of toe tendon", "code_information": [ { "code": "28232", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 3908.91 } ] }, { "description": "Incision of foot tendon", "code_information": [ { "code": "28234", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 3908.91 } ] }, { "description": "Revision of foot tendon", "code_information": [ { "code": "28261", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2918.174022, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1823.858764, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1315.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1388.732594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1969.767465, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1765.495284, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1429.905271, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3908.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2334.539218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1761.158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1459.087011, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1600.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 3908.91 } ] }, { "description": "Release of foot contracture", "code_information": [ { "code": "28270", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Repair of hammertoe", "code_information": [ { "code": "28285", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Corrj halux rigdus w/o implt", "code_information": [ { "code": "28289", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Cor hlx vlgs rsc prx phlx bs", "code_information": [ { "code": "28292", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 7924.77 } ] }, { "description": "Cor hlx vlgs dstl mtar osteo", "code_information": [ { "code": "28296", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Cor hlx vlgs jt arthrd", "code_information": [ { "code": "28297", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23299.56312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14562.22695, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15727.20511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14096.23569, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11416.78593, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 31426.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18639.6505, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14061.6182, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12866.82 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 31426.44 } ] }, { "description": "Cor hlx vlgs prx phlx osteot", "code_information": [ { "code": "28298", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Cor hlx vlgs double osteot", "code_information": [ { "code": "28299", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 773.72, "maximum": 17448.13 } ] }, { "description": "Incision of heel bone", "code_information": [ { "code": "28300", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 17448.13 } ] }, { "description": "Incision of midfoot bones", "code_information": [ { "code": "28304", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 17448.13 } ] }, { "description": "Incise/graft midfoot bones", "code_information": [ { "code": "28305", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Incision of metatarsal", "code_information": [ { "code": "28308", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 7924.77 } ] }, { "description": "Revision of big toe", "code_information": [ { "code": "28310", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Repair of metatarsals", "code_information": [ { "code": "28322", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 17448.13 } ] }, { "description": "Treat heel fracture", "code_information": [ { "code": "28415", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Treat midfoot fracture each", "code_information": [ { "code": "28450", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 447.6504032, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 279.781502, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 223.8252016, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 209.34 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 220.944744 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 223.8252016, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 302.1640222, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 223.8252016, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.8284939, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 219.3486976, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 585.89, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 223.8252016, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 358.1203226, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 270.1664, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 223.8252016, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 239.88 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 209.34, "maximum": 585.89 } ] }, { "description": "Treat midfoot fracture each", "code_information": [ { "code": "28465", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Treat metatarsal fracture", "code_information": [ { "code": "28485", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 17448.13 } ] }, { "description": "Treat big toe fracture", "code_information": [ { "code": "28505", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Treat toe fracture", "code_information": [ { "code": "28525", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Repair foot dislocation", "code_information": [ { "code": "28555", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 17448.13 } ] }, { "description": "Repair foot dislocation", "code_information": [ { "code": "28585", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Repair foot dislocation", "code_information": [ { "code": "28615", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Repair toe dislocation", "code_information": [ { "code": "28645", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Arthrodesis triple", "code_information": [ { "code": "28715", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23299.56312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14562.22695, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15727.20511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14096.23569, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11416.78593, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 31426.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18639.6505, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14061.6182, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12866.82 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 31426.44 } ] }, { "description": "Arthrodesis subtalar", "code_information": [ { "code": "28725", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23299.56312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14562.22695, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15727.20511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14096.23569, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11416.78593, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 31426.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18639.6505, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14061.6182, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12866.82 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 31426.44 } ] }, { "description": "Fusion of foot bones", "code_information": [ { "code": "28730", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23299.56312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14562.22695, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15727.20511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14096.23569, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11416.78593, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 31426.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18639.6505, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14061.6182, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12866.82 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 31426.44 } ] }, { "description": "Fusion of foot bones", "code_information": [ { "code": "28735", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23299.56312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14562.22695, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15727.20511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14096.23569, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11416.78593, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 31426.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18639.6505, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14061.6182, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12866.82 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 31426.44 } ] }, { "description": "Fusion of foot bones", "code_information": [ { "code": "28740", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 17448.13 } ] }, { "description": "Fusion of big toe joint", "code_information": [ { "code": "28750", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 17448.13 } ] }, { "description": "Fusion of big toe joint", "code_information": [ { "code": "28755", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 17448.13 } ] }, { "description": "Amputation thru metatarsal", "code_information": [ { "code": "28805", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 2657.52, "maximum": 7924.77 } ] }, { "description": "Amputation toe & metatarsal", "code_information": [ { "code": "28810", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 7924.77 } ] }, { "description": "Amputation of toe", "code_information": [ { "code": "28820", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 7924.77 } ] }, { "description": "Partial amputation of toe", "code_information": [ { "code": "28825", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 7924.77 } ] }, { "description": "Unlisted px foot/toes", "code_information": [ { "code": "28899", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 447.6504032, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 279.781502, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 223.8252016, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 209.34 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 220.944744 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 223.8252016, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 302.1640222, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 223.8252016, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.8284939, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 219.3486976, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 585.89, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 223.8252016, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 358.1203226, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 270.1664, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 223.8252016, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 239.88 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 209.34, "maximum": 585.89 } ] }, { "description": "Sho arthrs srg capsulorraphy", "code_information": [ { "code": "29806", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Sho arthrs srg rpr slap les", "code_information": [ { "code": "29807", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Sho arthrs srg lmtd dbrdmt", "code_information": [ { "code": "29822", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Sho arthrs srg xtnsv dbrdmt", "code_information": [ { "code": "29823", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Sho arthrs srg dstl claviclc", "code_information": [ { "code": "29824", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 773.72, "maximum": 7924.77 } ] }, { "description": "Sho arthrs srg decompression", "code_information": [ { "code": "29826", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 6129.10597 } ] }, { "description": "Sho arthrs srg rt8tr cuf rpr", "code_information": [ { "code": "29827", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 773.72, "maximum": 17448.13 } ] }, { "description": "Hip arthr0 w/synovectomy", "code_information": [ { "code": "29863", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 7924.77 } ] }, { "description": "Knee arthroscopy/surgery", "code_information": [ { "code": "29873", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Knee arthroscopy/surgery", "code_information": [ { "code": "29874", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Knee arthroscopy/surgery", "code_information": [ { "code": "29875", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 7924.77 } ] }, { "description": "Knee arthroscopy/surgery", "code_information": [ { "code": "29876", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 7924.77 } ] }, { "description": "Knee arthroscopy/surgery", "code_information": [ { "code": "29879", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Knee arthroscopy/surgery", "code_information": [ { "code": "29880", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 7924.77 } ] }, { "description": "Knee arthroscopy/surgery", "code_information": [ { "code": "29881", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 7924.77 } ] }, { "description": "Knee arthroscopy/surgery", "code_information": [ { "code": "29882", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Knee arthroscopy/surgery", "code_information": [ { "code": "29888", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 17448.13 } ] }, { "description": "Ankle arthroscopy/surgery", "code_information": [ { "code": "29895", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5938.006838, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3711.254274, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2657.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2804.79127 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4008.154616, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3592.494137, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2909.623351, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7924.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4750.405471, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3583.6738, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2969.003419, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3244.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7924.77 } ] }, { "description": "Drainage of nose lesion", "code_information": [ { "code": "30000", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 429.8339136, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 268.646196, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 214.9169568, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 197.69 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 208.649544 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 214.9169568, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 290.1378917, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 214.9169568, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 260.0495177, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 210.6186177, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 567.18, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 214.9169568, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 343.8671309, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 259.4158, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 214.9169568, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 232.22 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 197.69, "maximum": 567.18 } ] }, { "description": "Removal of intranasal lesion", "code_information": [ { "code": "30117", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6016.875446, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3760.547154, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2542.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2683.724534 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4061.390926, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3640.209645, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2948.268969, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7921, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4813.500357, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3631.2724, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3243.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7921 } ] }, { "description": "Excise inferior turbinate", "code_information": [ { "code": "30130", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6016.875446, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3760.547154, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2542.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2683.724534 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4061.390926, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3640.209645, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2948.268969, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7921, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4813.500357, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3631.2724, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3243.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7921 } ] }, { "description": "Resect inferior turbinate", "code_information": [ { "code": "30140", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6016.875446, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3760.547154, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2542.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2683.724534 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4061.390926, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3640.209645, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2948.268969, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7921, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4813.500357, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3631.2724, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3243.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 7921 } ] }, { "description": "Nasal sinus therapy", "code_information": [ { "code": "30210", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2815.804701, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1759.877938, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1309.94 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1382.533764 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1900.668173, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1703.561844, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1379.744303, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3617.94, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2252.643761, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1699.3788, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1481.28 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 3617.94 } ] }, { "description": "Insert nasal septal button", "code_information": [ { "code": "30220", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2815.804701, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1759.877938, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1309.94 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1382.533764 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1900.668173, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1703.561844, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1379.744303, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3617.94, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2252.643761, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1699.3788, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1481.28 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 3617.94 } ] }, { "description": "Reconstruction of nose", "code_information": [ { "code": "30410", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 10743.27218, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6714.54511, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4708.89 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4969.853038 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7251.708719, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6499.679666, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5264.203366, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14448.64, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8594.617741, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6483.7192, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5915.66 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 773.72, "maximum": 14448.64 } ] }, { "description": "Reconstruction of nose", "code_information": [ { "code": "30420", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 10743.27218, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6714.54511, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4708.89 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4969.853038 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7251.708719, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6499.679666, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5264.203366, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14448.64, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8594.617741, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6483.7192, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5915.66 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 773.72, "maximum": 14448.64 } ] }, { "description": "Revision of nose", "code_information": [ { "code": "30450", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 10743.27218, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6714.54511, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4708.89 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4969.853038 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7251.708719, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6499.679666, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5264.203366, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14448.64, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8594.617741, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6483.7192, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5915.66 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1073.67, "maximum": 14448.64 } ] }, { "description": "Repair nasal stenosis", "code_information": [ { "code": "30465", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 10743.27218, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6714.54511, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4708.89 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4969.853038 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7251.708719, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6499.679666, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5264.203366, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14448.64, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8594.617741, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6483.7192, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5915.66 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1444.88, "maximum": 14448.64 } ] }, { "description": "Repair of nasal septum", "code_information": [ { "code": "30520", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6016.875446, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3760.547154, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2542.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2683.724534 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4061.390926, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3640.209645, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2948.268969, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7921, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4813.500357, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3631.2724, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3243.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 7921 } ] }, { "description": "Repair nasal septum defect", "code_information": [ { "code": "30630", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6016.875446, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3760.547154, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2542.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2683.724534 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4061.390926, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3640.209645, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2948.268969, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7921, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4813.500357, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3631.2724, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3243.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1073.67, "maximum": 7921 } ] }, { "description": "Ther fx nasal inf turbinate", "code_information": [ { "code": "30930", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6016.875446, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3760.547154, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2542.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2683.724534 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4061.390926, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3640.209645, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2948.268969, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7921, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4813.500357, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3631.2724, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3243.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 7921 } ] }, { "description": "Nsl/sinus endoscopy surg dcr", "code_information": [ { "code": "31239", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6766.180512, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4228.86282, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3383.090256, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2851.15 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3009.157986 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3383.090256, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4567.171846, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3383.090256, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4093.53921, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3315.428451, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 9005.15, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3383.090256, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5412.94441, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4083.4836, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3383.090256, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3686.95 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 9005.15 } ] }, { "description": "Nsl/sns ndsc cnch bull rescj", "code_information": [ { "code": "31240", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3230.149104, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2018.84319, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1615.074552, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1388.84 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1465.803006 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1615.074552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2180.350645, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1615.074552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1954.240208, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1582.773061, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4211.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1615.074552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2584.119283, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1949.4356, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1615.074552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1724.47 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 4211.91 } ] }, { "description": "Nsl/sins ndsc w/prtl ethmdct", "code_information": [ { "code": "31254", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 12807.83562, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8004.897264, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5281.5 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5574.192856 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8645.289045, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7748.740552, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6275.839455, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 16907.72, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10246.2685, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7729.7108, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6922.47 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 16907.72 } ] }, { "description": "Nsl/sins ndsc w/tot ethmdct", "code_information": [ { "code": "31255", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 12807.83562, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8004.897264, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5281.5 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5574.192856 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8645.289045, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7748.740552, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6275.839455, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 16907.72, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10246.2685, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7729.7108, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6922.47 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 773.72, "maximum": 16907.72 } ] }, { "description": "Nsl/sins ndsc sphn tiss rmvl", "code_information": [ { "code": "31259", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 12807.83562, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8004.897264, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5281.5 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5574.192856 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8645.289045, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7748.740552, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6275.839455, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 16907.72, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10246.2685, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7729.7108, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6922.47 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 16907.72 } ] }, { "description": "Endoscopy maxillary sinus", "code_information": [ { "code": "31267", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 12807.83562, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8004.897264, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5281.5 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5574.192856 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8645.289045, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7748.740552, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6275.839455, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 16907.72, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10246.2685, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7729.7108, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6922.47 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 16907.72 } ] }, { "description": "Nsl/sins ndsc frnt tiss rmvl", "code_information": [ { "code": "31276", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 12807.83562, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8004.897264, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5281.5 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5574.192856 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8645.289045, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7748.740552, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6275.839455, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 16907.72, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10246.2685, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7729.7108, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6403.917811, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6922.47 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 16907.72 } ] }, { "description": "Dx laryngoscopy excl nb", "code_information": [ { "code": "31525", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3230.149104, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2018.84319, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1615.074552, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1388.84 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1465.803006 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1615.074552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2180.350645, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1615.074552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1954.240208, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1582.773061, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4211.91, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1615.074552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2584.119283, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1949.4356, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1615.074552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1724.47 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 4211.91 } ] }, { "description": "Laryngoscopy w/biopsy", "code_information": [ { "code": "31535", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6766.180512, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4228.86282, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3383.090256, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2851.15 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3009.157986 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3383.090256, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4567.171846, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3383.090256, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4093.53921, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3315.428451, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 9005.15, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3383.090256, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5412.94441, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4083.4836, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3383.090256, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3686.95 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 9005.15 } ] }, { "description": "Rmvl & rplcmt dfb gen mlt ld", "code_information": [ { "code": "33264", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 56964.32647, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 35602.70405, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 28482.16324, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 31339.99 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 33076.79294 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 28482.16324, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 38450.92037, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 28482.16324, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 34463.41752, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 27912.51997, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 78308.49, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 28482.16324, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 45571.46118, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 34378.7724, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 28482.16324, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 32061.58 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 27912.51997, "maximum": 78308.49 } ] }, { "description": "MID LINE INSERTION DYNAMIC INFUSION", "code_information": [ { "code": "36410", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1336.72, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3.03 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3.0738 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 601.524 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 668.36 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 3.03, "maximum": 668.36 } ] }, { "description": "VENIPUNCTURE", "code_information": [ { "code": "36415", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15.6, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2.91 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3.0738 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.34, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.609, "additional_payer_notes": "not payable" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.34, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.3014, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.1532, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 25, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.34, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.944, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14.3836, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.34, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7.02 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 2.91, "maximum": 25 } ] }, { "description": "RT - VENIPUNCTURE BLOOD GAS", "code_information": [ { "code": "36415", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15.6, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2.91 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3.0738 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.34, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.609, "additional_payer_notes": "not payable" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.34, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.3014, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.1532, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 25, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.34, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.944, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14.3836, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.34, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7.02 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 2.91, "maximum": 25 } ] }, { "description": "BLOOD TRANSFUSION SERVICES", "code_information": [ { "code": "36430", "type": "CPT" }, { "code": "391", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1046.5, "discounted_cash": 800.6407136, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 500.400446, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 400.3203568, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 156.1378, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 376.71 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 397.585784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 400.3203568, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 156.1378, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 540.4324817, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 400.3203568, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 484.3876317, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 392.3139497, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 156.1378, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 156.1378, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1067.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 400.3203568, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 640.5125709, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 483.1988, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 400.3203568, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 437.18 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 470.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 523.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 156.1378, "maximum": 1067.8 } ] }, { "description": "Transfusion bld/bld compnt", "code_information": [ { "code": "36430", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 800.6407136, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 500.400446, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 400.3203568, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 376.71 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 397.585784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 400.3203568, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 540.4324817, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 400.3203568, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 484.3876317, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 392.3139497, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1067.79, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 400.3203568, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 640.5125709, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 483.1988, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 400.3203568, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 437.18 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 376.71, "maximum": 1067.79 } ] }, { "description": "PICC LINE INSERSTION", "code_information": [ { "code": "36569", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5484.7, "discounted_cash": 2856.76664, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1785.47915, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1428.38332, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1583.5 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1671.255798 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1428.38332, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1928.317482, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1428.38332, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1728.343817, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1399.815654, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3794.18, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1428.38332, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2285.413312, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1724.0944, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1428.38332, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1553.44 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2468.115 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2742.35 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 3794.18 } ] }, { "description": "Biopsy/removal lymph nodes", "code_information": [ { "code": "38510", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 7105.706317, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4441.066448, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3552.853158, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2941.09 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3104.07693 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3552.853158, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4796.351764, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3552.853158, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4298.952322, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3481.796095, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 9352.79, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3552.853158, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5684.565053, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4288.3918, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3552.853158, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3829.28 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 9352.79 } ] }, { "description": "Mediastinoscpy w/lmph nod bx", "code_information": [ { "code": "39402", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 10971.38719, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6857.116994, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4692.57 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4952.619266 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7405.686354, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6637.68925, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5375.979723, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14250.07, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8777.109752, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6621.3896, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5834.36 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 4692.57, "maximum": 14250.07 } ] }, { "description": "Excision of mouth lesion", "code_information": [ { "code": "40816", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6016.875446, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3760.547154, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2542.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2683.724534 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4061.390926, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3640.209645, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2948.268969, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7921, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4813.500357, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3631.2724, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3243.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 7921 } ] }, { "description": "Excision of tongue fold", "code_information": [ { "code": "41115", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2815.804701, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1759.877938, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1309.94 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1382.533764 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1900.668173, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1703.561844, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1379.744303, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3617.94, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2252.643761, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1699.3788, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1481.28 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 3617.94 } ] }, { "description": "Excision lesion mouth roof", "code_information": [ { "code": "42106", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6016.875446, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3760.547154, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2542.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2683.724534 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4061.390926, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3640.209645, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2948.268969, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7921, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4813.500357, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3631.2724, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3243.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 7921 } ] }, { "description": "Excision lesion mouth roof", "code_information": [ { "code": "42107", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 10743.27218, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6714.54511, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4708.89 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4969.853038 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7251.708719, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6499.679666, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5264.203366, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14448.64, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8594.617741, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6483.7192, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5915.66 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 14448.64 } ] }, { "description": "Excision of uvula", "code_information": [ { "code": "42140", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6016.875446, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3760.547154, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2542.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2683.724534 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4061.390926, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3640.209645, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2948.268969, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7921, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4813.500357, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3631.2724, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3243.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 7921 } ] }, { "description": "Excise parotid gland/lesion", "code_information": [ { "code": "42415", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 10743.27218, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6714.54511, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4708.89 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4969.853038 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7251.708719, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6499.679666, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5264.203366, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14448.64, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8594.617741, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6483.7192, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5915.66 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1073.67, "maximum": 14448.64 } ] }, { "description": "Biopsy of throat", "code_information": [ { "code": "42800", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2815.804701, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1759.877938, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1309.94 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1382.533764 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1900.668173, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1703.561844, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1379.744303, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3617.94, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2252.643761, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1699.3788, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1481.28 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 3617.94 } ] }, { "description": "Biopsy of upper nose/throat", "code_information": [ { "code": "42806", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6016.875446, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3760.547154, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2542.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2683.724534 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4061.390926, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3640.209645, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2948.268969, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7921, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4813.500357, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3631.2724, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3243.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 7921 } ] }, { "description": "Excision of neck cyst", "code_information": [ { "code": "42815", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 10743.27218, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6714.54511, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4708.89 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4969.853038 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7251.708719, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6499.679666, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5264.203366, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14448.64, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8594.617741, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6483.7192, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5915.66 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 773.72, "maximum": 14448.64 } ] }, { "description": "Remove tonsils and adenoids", "code_information": [ { "code": "42820", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 10743.27218, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6714.54511, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4708.89 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4969.853038 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7251.708719, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6499.679666, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5264.203366, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14448.64, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8594.617741, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6483.7192, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5915.66 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 14448.64 } ] }, { "description": "Remove tonsils and adenoids", "code_information": [ { "code": "42821", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6016.875446, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3760.547154, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2542.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2683.724534 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4061.390926, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3640.209645, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2948.268969, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7921, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4813.500357, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3631.2724, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3243.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 773.72, "maximum": 7921 } ] }, { "description": "Removal of tonsils", "code_information": [ { "code": "42826", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6016.875446, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3760.547154, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2542.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2683.724534 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4061.390926, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3640.209645, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2948.268969, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7921, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4813.500357, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3631.2724, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3243.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 7921 } ] }, { "description": "Removal of adenoids", "code_information": [ { "code": "42830", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6016.875446, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3760.547154, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2542.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2683.724534 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4061.390926, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3640.209645, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2948.268969, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7921, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4813.500357, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3631.2724, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3243.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 7921 } ] }, { "description": "Removal of adenoids", "code_information": [ { "code": "42831", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6016.875446, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3760.547154, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2542.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2683.724534 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4061.390926, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3640.209645, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2948.268969, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7921, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4813.500357, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3631.2724, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3243.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 7921 } ] }, { "description": "Esophagoscopy rigid trnso dx", "code_information": [ { "code": "43191", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3482.42207, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2176.513794, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1741.211035, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1511.92 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1595.71204 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1741.211035, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2350.634898, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1741.211035, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2106.865353, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1706.386814, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4633.28, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1741.211035, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2785.937656, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2101.6884, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1741.211035, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1896.99 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 4633.28 } ] }, { "description": "Esophagoscopy lesion ablate", "code_information": [ { "code": "43229", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6996.888954, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4373.055596, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3498.444477, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.335, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2911.51 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3072.857368 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3498.444477, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.335, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4722.900044, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3498.444477, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4233.117817, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3428.475587, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.335, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.335, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 9292.34, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3498.444477, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5597.511163, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4222.722, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3498.444477, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3804.53 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.335, "maximum": 9292.34 } ] }, { "description": "Egd diagnostic brush wash", "code_information": [ { "code": "43235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1645.991402, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1028.744626, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 822.9957008, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 762.97 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 805.253632 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 822.9957008, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1111.044196, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 822.9957008, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 995.824798, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 806.5357868, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2289.93, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 822.9957008, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1316.793121, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 993.377, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 822.9957008, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 937.56 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 2289.93 } ] }, { "description": "Egd biopsy single/multiple", "code_information": [ { "code": "43239", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1645.991402, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1028.744626, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 822.9957008, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 762.97 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 805.253632 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 822.9957008, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1111.044196, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 822.9957008, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 995.824798, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 806.5357868, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2289.93, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 822.9957008, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1316.793121, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 993.377, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 822.9957008, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 937.56 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 2289.93 } ] }, { "description": "Egd dilate stricture", "code_information": [ { "code": "43245", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3482.42207, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2176.513794, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1741.211035, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1511.92 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1595.71204 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1741.211035, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2350.634898, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1741.211035, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2106.865353, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1706.386814, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4633.28, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1741.211035, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2785.937656, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2101.6884, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1741.211035, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1896.99 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 4633.28 } ] }, { "description": "Egd guide wire insertion", "code_information": [ { "code": "43248", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1645.991402, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1028.744626, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 822.9957008, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 762.97 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 805.253632 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 822.9957008, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1111.044196, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 822.9957008, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 995.824798, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 806.5357868, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2289.93, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 822.9957008, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1316.793121, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 993.377, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 822.9957008, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 937.56 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 2289.93 } ] }, { "description": "Egd cautery tumor polyp", "code_information": [ { "code": "43250", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3482.42207, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2176.513794, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1741.211035, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1511.92 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1595.71204 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1741.211035, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2350.634898, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1741.211035, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2106.865353, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1706.386814, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4633.28, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1741.211035, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2785.937656, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2101.6884, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1741.211035, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1896.99 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 4633.28 } ] }, { "description": "Diagnostic sigmoidoscopy", "code_information": [ { "code": "45330", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1687.681632, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1054.80102, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 843.840816, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 741.57 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 782.671448 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 843.840816, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1139.185102, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 843.840816, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1021.047387, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 826.9639997, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2226.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 843.840816, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1350.145306, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1018.5434, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 843.840816, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 911.71 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 2226.8 } ] }, { "description": "Diagnostic colonoscopy", "code_information": [ { "code": "45378", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1687.681632, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1054.80102, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 843.840816, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 741.57 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 782.671448 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 843.840816, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1139.185102, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 843.840816, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1021.047387, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 826.9639997, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2226.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 843.840816, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1350.145306, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1018.5434, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 843.840816, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 911.71 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 2226.8 } ] }, { "description": "Colonoscopy and biopsy", "code_information": [ { "code": "45380", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2171.657779, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1357.286112, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 974.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1028.923812 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1465.869001, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1313.852956, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1064.112312, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2879.83, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1737.326223, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1310.6226, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1179.08 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 2879.83 } ] }, { "description": "Colonoscopy submucous njx", "code_information": [ { "code": "45381", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2171.657779, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1357.286112, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 974.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1028.923812 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1465.869001, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1313.852956, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1064.112312, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2879.83, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1737.326223, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1310.6226, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1179.08 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 2879.83 } ] }, { "description": "Colonoscopy w/lesion removal", "code_information": [ { "code": "45384", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2171.657779, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1357.286112, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 974.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1028.923812 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1465.869001, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1313.852956, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1064.112312, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2879.83, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1737.326223, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1310.6226, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1179.08 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 2879.83 } ] }, { "description": "Colonoscopy w/lesion removal", "code_information": [ { "code": "45385", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2171.657779, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1357.286112, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 974.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1028.923812 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1465.869001, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1313.852956, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1064.112312, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2879.83, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1737.326223, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1310.6226, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1179.08 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 2879.83 } ] }, { "description": "Colonoscopy w/ablation", "code_information": [ { "code": "45388", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2171.657779, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1357.286112, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 974.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1028.923812 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1465.869001, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1313.852956, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1064.112312, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2879.83, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1737.326223, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1310.6226, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1085.82889, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1179.08 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 2879.83 } ] }, { "description": "Remove int/ext hem 1 group", "code_information": [ { "code": "46255", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5037.25273, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3148.282956, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2518.626365, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2275.73 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2401.846828 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2518.626365, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3400.145592, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2518.626365, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3047.537901, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2468.253838, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6698.12, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2518.626365, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4029.802184, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3040.0482, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2518.626365, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2742.39 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 6698.12 } ] }, { "description": "Laparoscopic cholecystectomy", "code_information": [ { "code": "47562", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 10971.38719, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6857.116994, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4692.57 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4952.619266 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7405.686354, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6637.68925, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5375.979723, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14250.07, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8777.109752, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6621.3896, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5834.36 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 14250.07 } ] }, { "description": "Prp i/hern init reduc >5 yr", "code_information": [ { "code": "49505", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6497.689744, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4061.05609, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3018.55 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3185.829764 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4385.940577, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3931.102295, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3183.867975, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8619.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5198.151795, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3921.4504, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3529.06 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 8619.52 } ] }, { "description": "Rerepair ing hernia reduce", "code_information": [ { "code": "49520", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6497.689744, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4061.05609, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3018.55 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3185.829764 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4385.940577, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3931.102295, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3183.867975, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8619.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5198.151795, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3921.4504, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3529.06 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1073.67, "maximum": 8619.52 } ] }, { "description": "Rpr aa hrn 1st < 3 cm rdc", "code_information": [ { "code": "49591", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6497.689744, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4061.05609, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3018.55 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3185.829764 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4385.940577, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3931.102295, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3183.867975, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8619.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5198.151795, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3921.4504, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3529.06 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 773.72, "maximum": 8619.52 } ] }, { "description": "Rpr aa hrn 1st < 3 ncr/strn", "code_information": [ { "code": "49592", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 10971.38719, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6857.116994, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4692.57 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4952.619266 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7405.686354, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6637.68925, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5375.979723, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14250.07, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8777.109752, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6621.3896, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5834.36 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 773.72, "maximum": 14250.07 } ] }, { "description": "Remove renal tube w/fluoro", "code_information": [ { "code": "50389", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1265.450368, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 790.90648, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 632.725184, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 540.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 570.220638 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 632.725184, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 854.1789984, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 632.725184, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 765.5974726, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 620.0706803, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1630.26, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 632.725184, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1012.360294, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 763.714, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 632.725184, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 667.47 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 540.28, "maximum": 1630.26 } ] }, { "description": "Fragmenting of kidney stone", "code_information": [ { "code": "50590", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6397.114506, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3998.196566, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2930.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3092.796084 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4318.052291, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3870.254276, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3134.586108, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8423.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5117.691604, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3860.7492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3448.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 8423.9 } ] }, { "description": "Injection for ureter x-ray", "code_information": [ { "code": "50690", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 370.7, "maximum": 391.24351 } ] }, { "description": "Drain bl w/cath insertion", "code_information": [ { "code": "51102", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3793.615571, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2371.009732, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1719.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1815.13013 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2560.690511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2295.137421, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1858.87163, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5003.36, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3034.892457, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2289.5054, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2048.51 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1719.82, "maximum": 5003.36 } ] }, { "description": "Injection for bladder x-ray", "code_information": [ { "code": "51600", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 226.24, "maximum": 238.772784 } ] }, { "description": "Injection for bladder x-ray", "code_information": [ { "code": "51610", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 226.24, "maximum": 238.772784 } ] }, { "description": "Change of bladder tube", "code_information": [ { "code": "51710", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1265.450368, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 790.90648, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 632.725184, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 540.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 570.220638 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 632.725184, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 854.1789984, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 632.725184, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 765.5974726, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 620.0706803, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1630.26, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 632.725184, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1012.360294, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 763.714, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 632.725184, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 667.47 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 1630.26 } ] }, { "description": "Endoscopic injection/implant", "code_information": [ { "code": "51715", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6397.114506, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3998.196566, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2930.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3092.796084 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4318.052291, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3870.254276, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3134.586108, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8423.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5117.691604, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3860.7492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3448.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 8423.9 } ] }, { "description": "Laparo sling operation", "code_information": [ { "code": "51992", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 10971.38719, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6857.116994, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4692.57 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4952.619266 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7405.686354, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6637.68925, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5375.979723, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14250.07, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8777.109752, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6621.3896, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5834.36 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 14250.07 } ] }, { "description": "Cystourethroscopy", "code_information": [ { "code": "52000", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1265.450368, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 790.90648, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 632.725184, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 540.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 570.220638 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 632.725184, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 854.1789984, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 632.725184, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 765.5974726, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 620.0706803, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1630.26, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 632.725184, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1012.360294, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 763.714, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 632.725184, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 667.47 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 1630.26 } ] }, { "description": "Cysto w/irrg&evac mlt clots", "code_information": [ { "code": "52001", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6397.114506, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3998.196566, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2930.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3092.796084 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4318.052291, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3870.254276, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3134.586108, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8423.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5117.691604, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3860.7492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3448.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 8423.9 } ] }, { "description": "Cysto w/urtrl cathj", "code_information": [ { "code": "52005", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3793.615571, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2371.009732, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1719.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1815.13013 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2560.690511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2295.137421, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1858.87163, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5003.36, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3034.892457, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2289.5054, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2048.51 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 5003.36 } ] }, { "description": "Cystoscopy w/biopsy(s)", "code_information": [ { "code": "52204", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3793.615571, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2371.009732, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1719.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1815.13013 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2560.690511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2295.137421, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1858.87163, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5003.36, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3034.892457, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2289.5054, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2048.51 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 5003.36 } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52214", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6397.114506, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3998.196566, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1719.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1815.13013 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4318.052291, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3870.254276, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3134.586108, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8423.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5117.691604, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3860.7492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3448.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 8423.9 } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52224", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6397.114506, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3998.196566, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1719.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1815.13013 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4318.052291, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3870.254276, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3134.586108, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8423.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5117.691604, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3860.7492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3448.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 8423.9 } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52234", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6397.114506, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3998.196566, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2930.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3092.796084 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4318.052291, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3870.254276, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3134.586108, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8423.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5117.691604, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3860.7492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3448.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 8423.9 } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52235", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6397.114506, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3998.196566, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2930.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3092.796084 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4318.052291, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3870.254276, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3134.586108, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8423.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5117.691604, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3860.7492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3448.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 8423.9 } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52240", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 9730.556618, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6081.597886, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4108.06 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4335.717852 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6568.125717, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5886.986754, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4767.972743, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 12416.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7784.445294, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5872.5226, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5083.62 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 12416.44 } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52260", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3793.615571, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2371.009732, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1719.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1815.13013 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2560.690511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2295.137421, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1858.87163, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5003.36, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3034.892457, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2289.5054, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2048.51 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 5003.36 } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52276", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3793.615571, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2371.009732, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1719.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1815.13013 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2560.690511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2295.137421, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1858.87163, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5003.36, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3034.892457, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2289.5054, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2048.51 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 5003.36 } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52281", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3793.615571, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2371.009732, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1719.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1815.13013 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2560.690511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2295.137421, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1858.87163, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5003.36, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3034.892457, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2289.5054, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2048.51 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 5003.36 } ] }, { "description": "Cystoscopy chemodenervation", "code_information": [ { "code": "52287", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3793.615571, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2371.009732, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1719.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1815.13013 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2560.690511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2295.137421, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1858.87163, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5003.36, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3034.892457, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2289.5054, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2048.51 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 5003.36 } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52310", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3793.615571, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2371.009732, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1719.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1815.13013 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2560.690511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2295.137421, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1858.87163, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5003.36, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3034.892457, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2289.5054, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2048.51 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 5003.36 } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52315", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3793.615571, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2371.009732, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1719.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1815.13013 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2560.690511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2295.137421, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1858.87163, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5003.36, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3034.892457, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2289.5054, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2048.51 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 5003.36 } ] }, { "description": "Remove bladder stone", "code_information": [ { "code": "52317", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6397.114506, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3998.196566, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2930.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3092.796084 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4318.052291, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3870.254276, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3134.586108, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8423.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5117.691604, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3860.7492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3448.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 8423.9 } ] }, { "description": "Remove bladder stone", "code_information": [ { "code": "52318", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6397.114506, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3998.196566, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2930.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3092.796084 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4318.052291, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3870.254276, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3134.586108, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8423.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5117.691604, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3860.7492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3448.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 8423.9 } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52330", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6397.114506, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3998.196566, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2930.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3092.796084 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4318.052291, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3870.254276, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3134.586108, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8423.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5117.691604, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3860.7492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3448.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 8423.9 } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52332", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6397.114506, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3998.196566, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2930.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3092.796084 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4318.052291, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3870.254276, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3134.586108, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8423.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5117.691604, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3860.7492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3448.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 8423.9 } ] }, { "description": "Cysto w/up stricture tx", "code_information": [ { "code": "52342", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6397.114506, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3998.196566, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2930.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3092.796084 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4318.052291, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3870.254276, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3134.586108, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8423.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5117.691604, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3860.7492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3448.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 8423.9 } ] }, { "description": "Cysto/uretero stricture tx", "code_information": [ { "code": "52344", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6397.114506, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3998.196566, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2930.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3092.796084 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4318.052291, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3870.254276, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3134.586108, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8423.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5117.691604, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3860.7492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3448.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 8423.9 } ] }, { "description": "Cysto/uretero w/up stricture", "code_information": [ { "code": "52345", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6397.114506, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3998.196566, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2930.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3092.796084 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4318.052291, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3870.254276, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3134.586108, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8423.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5117.691604, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3860.7492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3448.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 8423.9 } ] }, { "description": "Cystouretero & or pyeloscope", "code_information": [ { "code": "52351", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6397.114506, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3998.196566, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2930.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3092.796084 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4318.052291, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3870.254276, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3134.586108, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8423.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5117.691604, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3860.7492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3448.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 8423.9 } ] }, { "description": "Cystouretero w/stone remove", "code_information": [ { "code": "52352", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6397.114506, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3998.196566, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2930.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3092.796084 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4318.052291, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3870.254276, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3134.586108, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8423.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5117.691604, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3860.7492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3448.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 8423.9 } ] }, { "description": "Cystouretero w/lithotripsy", "code_information": [ { "code": "52353", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 9730.556618, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6081.597886, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4108.06 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4335.717852 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6568.125717, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5886.986754, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4767.972743, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 12416.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7784.445294, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5872.5226, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5083.62 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 12416.44 } ] }, { "description": "Cystouretero w/biopsy", "code_information": [ { "code": "52354", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 9730.556618, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6081.597886, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4108.06 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4335.717852 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6568.125717, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5886.986754, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4767.972743, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 12416.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7784.445294, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5872.5226, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5083.62 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 12416.44 } ] }, { "description": "Cysto/uretero w/lithotripsy", "code_information": [ { "code": "52356", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 9730.556618, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6081.597886, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4108.06 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4335.717852 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6568.125717, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5886.986754, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4767.972743, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 12416.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7784.445294, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5872.5226, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5083.62 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 12416.44 } ] }, { "description": "Revision of bladder neck", "code_information": [ { "code": "52500", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6397.114506, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3998.196566, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2930.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3092.796084 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4318.052291, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3870.254276, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3134.586108, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8423.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5117.691604, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3860.7492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3448.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 8423.9 } ] }, { "description": "Prostatectomy (turp)", "code_information": [ { "code": "52601", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 9730.556618, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6081.597886, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4108.06 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4335.717852 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6568.125717, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5886.986754, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4767.972743, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 12416.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7784.445294, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5872.5226, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5083.62 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 12416.44 } ] }, { "description": "Remove prostate regrowth", "code_information": [ { "code": "52630", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 9730.556618, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6081.597886, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4108.06 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4335.717852 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6568.125717, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5886.986754, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4767.972743, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 12416.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7784.445294, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5872.5226, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5083.62 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 12416.44 } ] }, { "description": "Laser surgery of prostate", "code_information": [ { "code": "52648", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 9730.556618, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6081.597886, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4108.06 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4335.717852 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6568.125717, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5886.986754, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4767.972743, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 12416.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7784.445294, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5872.5226, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5083.62 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1444.88, "maximum": 12416.44 } ] }, { "description": "Incision of urethra", "code_information": [ { "code": "53020", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3793.615571, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2371.009732, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1719.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1815.13013 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2560.690511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2295.137421, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1858.87163, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5003.36, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3034.892457, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2289.5054, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2048.51 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 5003.36 } ] }, { "description": "Removal of urethra lesion", "code_information": [ { "code": "53230", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 9730.556618, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6081.597886, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4108.06 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4335.717852 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6568.125717, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5886.986754, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4767.972743, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 12416.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7784.445294, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5872.5226, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5083.62 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 12416.44 } ] }, { "description": "Reconstruction of urethra", "code_information": [ { "code": "53410", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 9730.556618, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6081.597886, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4108.06 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4335.717852 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6568.125717, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5886.986754, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4767.972743, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 12416.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7784.445294, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5872.5226, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5083.62 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 12416.44 } ] }, { "description": "Excision of penis lesion(s)", "code_information": [ { "code": "54060", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3744.42927, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2340.268294, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1575.36 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1662.659404 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2527.489758, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2265.379709, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1834.770342, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4467.78, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2995.543416, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2259.8114, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1829.23 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 4467.78 } ] }, { "description": "Destruction penis lesion(s)", "code_information": [ { "code": "54065", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3744.42927, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2340.268294, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1575.36 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1662.659404 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2527.489758, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2265.379709, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1834.770342, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4467.78, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2995.543416, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2259.8114, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1872.214635, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1829.23 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 4467.78 } ] }, { "description": "Circum 28 days or older", "code_information": [ { "code": "54161", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3793.615571, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2371.009732, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1719.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1815.13013 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2560.690511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2295.137421, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1858.87163, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5003.36, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3034.892457, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2289.5054, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2048.51 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 5003.36 } ] }, { "description": "Lysis penil circumic lesion", "code_information": [ { "code": "54162", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3793.615571, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2371.009732, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1719.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1815.13013 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2560.690511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2295.137421, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1858.87163, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5003.36, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3034.892457, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2289.5054, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2048.51 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 5003.36 } ] }, { "description": "Repair of circumcision", "code_information": [ { "code": "54163", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3793.615571, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2371.009732, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1719.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1815.13013 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2560.690511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2295.137421, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1858.87163, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5003.36, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3034.892457, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2289.5054, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2048.51 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 5003.36 } ] }, { "description": "Penis plastic surgery", "code_information": [ { "code": "54360", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6397.114506, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3998.196566, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2930.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3092.796084 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4318.052291, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3870.254276, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3134.586108, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8423.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5117.691604, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3860.7492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3448.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 8423.9 } ] }, { "description": "Remove muti-comp penis pros", "code_information": [ { "code": "54406", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6397.114506, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3998.196566, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2930.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3092.796084 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4318.052291, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3870.254276, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3134.586108, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8423.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5117.691604, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3860.7492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3448.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 8423.9 } ] }, { "description": "Preputial stretching", "code_information": [ { "code": "54450", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 453.4234432, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 283.389652, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 226.7117216, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 228.04 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 240.67854 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 226.7117216, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 306.0608242, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 226.7117216, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 274.3211831, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 222.1774872, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 594.03, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 226.7117216, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 362.7387546, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 273.6454, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 226.7117216, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 243.21 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 222.1774872, "maximum": 594.03 } ] }, { "description": "Removal of testis", "code_information": [ { "code": "54520", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6397.114506, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3998.196566, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2930.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3092.796084 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4318.052291, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3870.254276, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3134.586108, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8423.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5117.691604, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3860.7492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3448.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 8423.9 } ] }, { "description": "Removal of testis", "code_information": [ { "code": "54530", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6497.689744, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4061.05609, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3018.55 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3185.829764 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4385.940577, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3931.102295, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3183.867975, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8619.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5198.151795, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3921.4504, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3529.06 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 8619.52 } ] }, { "description": "Orchiopexy ingun/scrot appr", "code_information": [ { "code": "54640", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6497.689744, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4061.05609, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3018.55 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3185.829764 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4385.940577, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3931.102295, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3183.867975, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8619.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5198.151795, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3921.4504, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3529.06 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 8619.52 } ] }, { "description": "Revision of testis", "code_information": [ { "code": "54660", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 9730.556618, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6081.597886, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4108.06 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4335.717852 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6568.125717, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5886.986754, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4767.972743, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 12416.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7784.445294, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5872.5226, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4865.278309, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5083.62 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 12416.44 } ] }, { "description": "Drainage of scrotum", "code_information": [ { "code": "54700", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3793.615571, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2371.009732, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1719.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1815.13013 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2560.690511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2295.137421, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1858.87163, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5003.36, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3034.892457, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2289.5054, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2048.51 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 5003.36 } ] }, { "description": "Remove epididymis lesion", "code_information": [ { "code": "54840", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3793.615571, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2371.009732, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1719.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1815.13013 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2560.690511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2295.137421, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1858.87163, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5003.36, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3034.892457, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2289.5054, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2048.51 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 5003.36 } ] }, { "description": "Removal of epididymis", "code_information": [ { "code": "54860", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6397.114506, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3998.196566, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1719.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1815.13013 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4318.052291, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3870.254276, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3134.586108, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8423.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5117.691604, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3860.7492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3448.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1719.82, "maximum": 8423.9 } ] }, { "description": "Removal of hydrocele", "code_information": [ { "code": "55040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6497.689744, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4061.05609, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3018.55 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3185.829764 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4385.940577, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3931.102295, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3183.867975, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8619.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5198.151795, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3921.4504, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3248.844872, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3529.06 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 8619.52 } ] }, { "description": "Explore scrotum", "code_information": [ { "code": "55110", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6397.114506, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3998.196566, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2930.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3092.796084 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4318.052291, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3870.254276, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3134.586108, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8423.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5117.691604, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3860.7492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3198.557253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3448.97 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 8423.9 } ] }, { "description": "Removal of sperm duct(s)", "code_information": [ { "code": "55250", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3793.615571, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2371.009732, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1719.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1815.13013 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2560.690511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2295.137421, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1858.87163, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5003.36, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3034.892457, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2289.5054, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1896.807786, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2048.51 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 5003.36 } ] }, { "description": "Abltj mal prst8 tiss hifu", "code_information": [ { "code": "55880", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 17179.67888, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10737.2993, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8589.83944, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4108.06 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4335.717852 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8589.83944, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11596.28324, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8589.83944, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10393.70572, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8418.042651, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 22585.61, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8589.83944, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13743.7431, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 10368.1746, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8589.83944, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12960 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1073.67, "maximum": 22585.61 } ] }, { "description": "Lysis of labial adhesions", "code_information": [ { "code": "56441", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5874.716557, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3671.697848, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2937.358278, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2425.16 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2559.55326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2937.358278, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3965.433676, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2937.358278, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3554.203517, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2878.611113, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7765.81, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2937.358278, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4699.773245, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3545.4734, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2937.358278, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3179.53 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 7765.81 } ] }, { "description": "Anterior colporrhaphy", "code_information": [ { "code": "57240", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 9078.416256, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5674.01016, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4539.208128, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4146.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4376.619884 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4539.208128, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6127.930973, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4539.208128, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5492.441835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4448.423965, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 12056.98, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4539.208128, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7262.733005, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5478.9546, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4539.208128, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4936.45 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 773.72, "maximum": 12056.98 } ] }, { "description": "Revise/remove sling repair", "code_information": [ { "code": "57287", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5874.716557, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3671.697848, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2937.358278, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2425.16 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2559.55326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2937.358278, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3965.433676, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2937.358278, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3554.203517, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2878.611113, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7765.81, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2937.358278, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4699.773245, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3545.4734, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2937.358278, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3179.53 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 2425.16, "maximum": 7765.81 } ] }, { "description": "Repair bladder defect", "code_information": [ { "code": "57288", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 9078.416256, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5674.01016, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4539.208128, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4146.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4376.619884 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4539.208128, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6127.930973, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4539.208128, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5492.441835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4448.423965, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 12056.98, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4539.208128, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7262.733005, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5478.9546, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4539.208128, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4936.45 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 773.72, "maximum": 12056.98 } ] }, { "description": "Hysteroscopy biopsy", "code_information": [ { "code": "58558", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5874.716557, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3671.697848, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2937.358278, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2425.16 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2559.55326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2937.358278, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3965.433676, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2937.358278, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3554.203517, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2878.611113, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7765.81, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2937.358278, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4699.773245, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3545.4734, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2937.358278, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3179.53 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 7765.81 } ] }, { "description": "Laparoscopy remove adnexa", "code_information": [ { "code": "58661", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 10971.38719, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6857.116994, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4692.57 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4952.619266 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7405.686354, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6637.68925, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5375.979723, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14250.07, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8777.109752, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6621.3896, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5834.36 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 773.72, "maximum": 14250.07 } ] }, { "description": "Biopsy of thyroid", "code_information": [ { "code": "60100", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1285.11423, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 803.196394, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 642.5571152, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 592.2 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 625.016246 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 642.5571152, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 867.4521055, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 642.5571152, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 777.4941094, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 629.7059729, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1718.48, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 642.5571152, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1028.091384, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 775.5818, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 642.5571152, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 703.59 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 1718.48 } ] }, { "description": "Removal of thyroid", "code_information": [ { "code": "60240", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 10971.38719, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6857.116994, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4692.57 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4952.619266 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7405.686354, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6637.68925, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5375.979723, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14250.07, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8777.109752, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6621.3896, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5485.693595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5834.36 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1444.88, "maximum": 14250.07 } ] }, { "description": "Repeat thyroid surgery", "code_information": [ { "code": "60260", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 10743.27218, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6714.54511, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4708.89 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4969.853038 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7251.708719, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6499.679666, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5264.203366, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14448.64, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8594.617741, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6483.7192, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5915.66 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 4708.89, "maximum": 14448.64 } ] }, { "description": "Removal of thyroid", "code_information": [ { "code": "60271", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 10743.27218, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6714.54511, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4708.89 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4969.853038 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7251.708719, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6499.679666, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5264.203366, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14448.64, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8594.617741, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6483.7192, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5371.636088, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5915.66 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 4708.89, "maximum": 14448.64 } ] }, { "description": "Brain canal shunt procedure", "code_information": [ { "code": "61070", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1281.028694, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 800.642934, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 606.8 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 640.42623 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 864.6943687, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 775.0223601, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 627.7040603, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1691.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1024.822956, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 773.122, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 692.52 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 1691.44 } ] }, { "description": "Scan proc cranial extra", "code_information": [ { "code": "61782", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 0.01, "maximum": 0.010246 } ] }, { "description": "Dx lmbr spi pnxr", "code_information": [ { "code": "62270", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1281.028694, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 800.642934, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 606.8 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 640.42623 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 864.6943687, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 775.0223601, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 627.7040603, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1691.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1024.822956, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 773.122, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 692.52 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 1691.44 } ] }, { "description": "Injection for myelogram", "code_information": [ { "code": "62284", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 370.7, "maximum": 391.24351 } ] }, { "description": "Njx px discography lumbar", "code_information": [ { "code": "62290", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1669.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1761.64601 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1669.14, "maximum": 5000 } ] }, { "description": "Myelography lumbar injection", "code_information": [ { "code": "62302", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1422.654688, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 889.15918, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 660.94 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 697.568172 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 960.2919144, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 860.7060862, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 697.1007971, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1929.67, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1138.12375, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 858.5878, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 790.06 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 660.94, "maximum": 1929.67 } ] }, { "description": "Myelography lumbar injection", "code_information": [ { "code": "62304", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1422.654688, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 889.15918, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 660.94 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 697.568172 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 960.2919144, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 860.7060862, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 697.1007971, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1929.67, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1138.12375, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 858.5878, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 790.06 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 6756.93, "10th_percentile": 6756.93, "90th_percentile": 6756.93, "count": "1 through 10" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 660.94, "maximum": 1929.67 } ] }, { "description": "Myelography lumbar injection", "code_information": [ { "code": "62305", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1422.654688, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 889.15918, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 660.94 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 697.568172 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 960.2919144, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 860.7060862, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 697.1007971, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1929.67, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1138.12375, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 858.5878, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 790.06 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 660.94, "maximum": 1929.67 } ] }, { "description": "Njx interlaminar crv/thrc", "code_information": [ { "code": "62321", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1281.028694, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 800.642934, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 606.8 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 640.42623 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 864.6943687, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 775.0223601, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 627.7040603, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "median_amount": 3150, "10th_percentile": 2870, "90th_percentile": 3430, "count": "1 through 10", "additional_payer_notes": "paid via surg time charge" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1691.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1024.822956, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 773.122, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 692.52 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 3000 } ] }, { "description": "Njx interlaminar lmbr/sac", "code_information": [ { "code": "62323", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1281.028694, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 800.642934, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 606.8 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 640.42623 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 864.6943687, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 775.0223601, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 627.7040603, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "median_amount": 2700, "10th_percentile": 2580, "90th_percentile": 2860, "count": "1 through 10", "additional_payer_notes": "paid via surg time charge" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1691.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1024.822956, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 773.122, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 692.52 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 3000 } ] }, { "description": "Implant spinal canal cath", "code_information": [ { "code": "62350", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 15926.36078, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9953.975486, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5348.15 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5644.531646 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10750.29352, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9635.44827, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7803.916781, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 15641.56, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12741.08862, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 9611.7812, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6404.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 15641.56 } ] }, { "description": "Remove spinal canal catheter", "code_information": [ { "code": "62355", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3543.793926, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2214.871204, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1669.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1761.64601 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2392.0609, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2143.995325, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1736.459024, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4769.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2835.035141, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2138.7324, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1952.77 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 4769.52 } ] }, { "description": "Insert spine infusion device", "code_information": [ { "code": "62360", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 32709.5828, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20443.48925, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16354.7914, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 16034.16 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 16922.74442 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16354.7914, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22078.96839, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16354.7914, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19789.29759, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16027.69557, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 43167.98, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16354.7914, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 26167.66624, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 19740.6888, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16354.7914, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 17674.12 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 43167.98 } ] }, { "description": "Implant spine infusion pump", "code_information": [ { "code": "62362", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 32709.5828, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20443.48925, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16354.7914, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 16034.16 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 16922.74442 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16354.7914, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22078.96839, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16354.7914, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19789.29759, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16027.69557, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 43167.98, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16354.7914, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 26167.66624, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 19740.6888, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16354.7914, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 17674.12 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 43167.98 } ] }, { "description": "Remove spine infusion device", "code_information": [ { "code": "62365", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6199.605485, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3874.753428, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3099.802742, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5348.15 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5644.531646 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3099.802742, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4184.733702, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3099.802742, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3750.761318, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3037.806688, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 15641.56, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3099.802742, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4959.684388, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3741.5518, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3099.802742, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6404.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 15641.56 } ] }, { "description": "Ndsc dcmprn 1 ntrspc lumbar", "code_information": [ { "code": "62380", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1444.88, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1444.88, "maximum": 17448.13 } ] }, { "description": "Neck spine disk surgery", "code_information": [ { "code": "63020", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 5807.28, "maximum": 17448.13 } ] }, { "description": "Low back disk surgery", "code_information": [ { "code": "63030", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 5807.28, "maximum": 17448.13 } ] }, { "description": "Spinal disk surgery add-on", "code_information": [ { "code": "63035", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 0.01, "maximum": 0.010246 } ] }, { "description": "Laminotomy single lumbar", "code_information": [ { "code": "63042", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 5807.28, "maximum": 17448.13 } ] }, { "description": "Lam facetec & foramot crv", "code_information": [ { "code": "63045", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 5807.28, "maximum": 17448.13 } ] }, { "description": "Lam facetec & foramot lumbar", "code_information": [ { "code": "63047", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 5807.28, "maximum": 17448.13 } ] }, { "description": "Lam facetec &foramot ea addl", "code_information": [ { "code": "63048", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 0.01, "maximum": 0.010246 } ] }, { "description": "Lam facetc/frmt arthrd lum 1", "code_information": [ { "code": "63052", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 0.01, "maximum": 0.010246 } ] }, { "description": "Lam factc/frmt arthrd lum ea", "code_information": [ { "code": "63053", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 0.01, "maximum": 0.010246 } ] }, { "description": "Decompress spinal cord lmbr", "code_information": [ { "code": "63056", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.15, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 5807.28, "maximum": 17448.15 } ] }, { "description": "Excise intrspinl lesion lmbr", "code_information": [ { "code": "63267", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13168.53516, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8230.334476, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5807.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6129.10597 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8888.761234, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7966.963773, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6452.582229, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17448.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10534.82813, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7947.3982, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6584.267581, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7143.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 5807.28, "maximum": 17448.13 } ] }, { "description": "Implant neuroelectrodes", "code_information": [ { "code": "63650", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 11565.67281, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7228.545506, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6006.47 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6339.333398 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7806.829146, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6997.23205, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5667.179677, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 16029.49, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9252.538248, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6980.05, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6562.9 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 16029.49 } ] }, { "description": "Implant neuroelectrodes", "code_information": [ { "code": "63655", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 35207.21306, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22004.50816, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17603.60653, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 18716.46 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 19753.69373 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17603.60653, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 23764.86881, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17603.60653, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21300.3639, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17251.5344, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 52376.64, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17603.60653, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 28165.77045, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 21248.0464, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17603.60653, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 21444.39 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 17251.5344, "maximum": 52376.64 } ] }, { "description": "Remove spine eltrd perq aray", "code_information": [ { "code": "63661", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3543.793926, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2214.871204, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1669.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1761.64601 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2392.0609, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2143.995325, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1736.459024, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4769.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2835.035141, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2138.7324, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1952.77 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 4769.52 } ] }, { "description": "Remove spine eltrd plate", "code_information": [ { "code": "63662", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6344.713066, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3965.445666, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3056.56 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3225.9531 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4282.681319, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3838.551405, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3108.909402, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8399.58, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5075.770452, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3829.1246, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3439.01 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 8399.58 } ] }, { "description": "Revise spine eltrd perq aray", "code_information": [ { "code": "63663", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 11565.67281, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7228.545506, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6006.47 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6339.333398 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7806.829146, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6997.23205, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5667.179677, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 16029.49, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9252.538248, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6980.05, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6562.9 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 16029.49 } ] }, { "description": "Ins/rplc spi npg/rcvr pocket", "code_information": [ { "code": "63685", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 56000.3709, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 35000.23181, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 28000.18545, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 28268.47 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 29835.061 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 28000.18545, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 37800.25036, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 28000.18545, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 33880.22439, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 27440.18174, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 74429.92, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 28000.18545, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 44800.29672, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 33797.015, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 28000.18545, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 30473.59 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 74429.92 } ] }, { "description": "Rev/rmv imp sp npg/r dtch cn", "code_information": [ { "code": "63688", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6344.713066, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3965.445666, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3056.56 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3225.9531 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4282.681319, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3838.551405, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3108.909402, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8399.58, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5075.770452, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3829.1246, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3439.01 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 8399.58 } ] }, { "description": "Njx aa&/strd gr ocpl nrv", "code_information": [ { "code": "64405", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 557.053952, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 348.15872, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 254.13 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 268.209542 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 376.0114176, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 337.017641, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 272.9564365, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 720.98, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 445.6431616, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 336.189, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 295.19 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 254.13, "maximum": 720.98 } ] }, { "description": "Njx aa&/strd ntrcost nrv 1", "code_information": [ { "code": "64420", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1281.028694, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 800.642934, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 606.8 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 640.42623 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 864.6943687, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 775.0223601, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 627.7040603, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1691.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1024.822956, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 773.122, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 692.52 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 1691.44 } ] }, { "description": "Njx aa&/strd ntrcost nrv ea", "code_information": [ { "code": "64421", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1605.136042, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1003.210026, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 788.34 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 832.02643 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1083.466828, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 971.1073052, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 786.5166604, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2174.48, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1284.108833, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 968.7202, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 890.29 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 2174.48 } ] }, { "description": "Njx aa&/strd pudendal nerve", "code_information": [ { "code": "64430", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1605.136042, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1003.210026, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 788.34 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 832.02643 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1083.466828, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 971.1073052, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 786.5166604, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2174.48, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1284.108833, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 968.7202, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 890.29 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 2174.48 } ] }, { "description": "Njx aa&/strd other pn/branch", "code_information": [ { "code": "64450", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1281.028694, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 800.642934, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 606.8 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 640.42623 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 864.6943687, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 775.0223601, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 627.7040603, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1691.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1024.822956, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 773.122, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 692.52 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 1691.44 } ] }, { "description": "Njx aa&/strd nrv nrvtg si jt", "code_information": [ { "code": "64451", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1281.028694, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 800.642934, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 606.8 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 640.42623 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 864.6943687, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 775.0223601, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 627.7040603, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1691.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1024.822956, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 773.122, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 692.52 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 1691.44 } ] }, { "description": "Njx aa&/strd gnclr nrv brnch", "code_information": [ { "code": "64454", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1281.028694, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 800.642934, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 606.8 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 640.42623 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 864.6943687, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 775.0223601, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 627.7040603, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1691.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1024.822956, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 773.122, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 1691.44 } ] }, { "description": "Njx aa&/strd tfrm epi c/t 1", "code_information": [ { "code": "64479", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1605.136042, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1003.210026, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 288.52, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 788.34 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 832.02643 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 288.52, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1083.466828, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 971.1073052, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 786.5166604, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 288.52, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 288.52, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2174.48, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1284.108833, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 968.7202, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 890.29 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 288.52, "maximum": 3000 } ] }, { "description": "Njx aa&/strd tfrm epi c/t ea", "code_information": [ { "code": "64480", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 288.52, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 288.52, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 288.52, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 288.52, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 0.01, "maximum": 3000 } ] }, { "description": "Njx aa&/strd tfrm epi l/s 1", "code_information": [ { "code": "64483", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1605.136042, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1003.210026, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 788.34 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 832.02643 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1083.466828, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 971.1073052, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 786.5166604, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "median_amount": 1400, "10th_percentile": 1400, "90th_percentile": 2750, "count": "1 through 10", "additional_payer_notes": "paid via surg time charge" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2174.48, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1284.108833, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 968.7202, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 890.29 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 6579.1, "10th_percentile": 6288, "90th_percentile": 6871, "count": "1 through 10" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 1462.5, "10th_percentile": 1072.5, "90th_percentile": 1462.5, "count": "1 through 10" } ], "minimum": 786.5166604, "maximum": 3000 } ] }, { "description": "Njx aa&/strd tfrm epi l/s ea", "code_information": [ { "code": "64484", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "median_amount": 1400, "10th_percentile": 1400, "90th_percentile": 1400, "count": "1 through 10", "additional_payer_notes": "paid via surg time charge" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 6579.1, "10th_percentile": 6288, "90th_percentile": 6871, "count": "1 through 10" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 1218.75, "10th_percentile": 975, "90th_percentile": 1462.5, "count": "1 through 10" } ], "minimum": 0.01, "maximum": 3000 } ] }, { "description": "Inj paravert f jnt c/t 1 lev", "code_information": [ { "code": "64490", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1605.136042, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1003.210026, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 788.34 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 832.02643 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1083.466828, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 971.1073052, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 786.5166604, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "median_amount": 1029, "10th_percentile": 1029, "90th_percentile": 1029, "count": "1 through 10", "additional_payer_notes": "paid via surg time charge" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2174.48, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1284.108833, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 968.7202, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 890.29 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 975, "10th_percentile": 975, "90th_percentile": 2145, "count": "1 through 10" } ], "minimum": 786.5166604, "maximum": 2174.48 } ] }, { "description": "Inj paravert f jnt c/t 2 lev", "code_information": [ { "code": "64491", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "median_amount": 1029, "10th_percentile": 1029, "90th_percentile": 1029, "count": "1 through 10", "additional_payer_notes": "paid via surg time charge" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 975, "10th_percentile": 975, "90th_percentile": 975, "count": "1 through 10" } ], "minimum": 0.01, "maximum": 1000 } ] }, { "description": "Inj paravert f jnt c/t 3 lev", "code_information": [ { "code": "64492", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "median_amount": 1029, "10th_percentile": 1029, "90th_percentile": 1029, "count": "1 through 10", "additional_payer_notes": "paid via surg time charge" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 975, "10th_percentile": 975, "90th_percentile": 975, "count": "1 through 10" } ], "minimum": 0.01, "maximum": 1000 } ] }, { "description": "Inj paravert f jnt l/s 1 lev", "code_information": [ { "code": "64493", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1605.136042, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1003.210026, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 788.34 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 832.02643 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1083.466828, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 971.1073052, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 786.5166604, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", 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"methodology": "fee schedule", "standard_charge_dollar": 1000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 975, "10th_percentile": 975, "90th_percentile": 975, "count": "1 through 10" } ], "minimum": 786.5166604, "maximum": 2174.48 } ] }, { "description": "Inj paravert f jnt l/s 2 lev", "code_information": [ { "code": "64494", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "median_amount": 1029, "10th_percentile": 1029, "90th_percentile": 1029, "count": "1 through 10", "additional_payer_notes": "paid via surg time charge" }, { "payer_name": "Prove Partners", "plan_name": "Prove 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{ "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "median_amount": 1029, "10th_percentile": 1029, "90th_percentile": 1029, "count": "1 through 10", "additional_payer_notes": "paid via surg time charge" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 6232, "10th_percentile": 6232, "90th_percentile": 6232, "count": "1 through 10" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 975, "10th_percentile": 975, "90th_percentile": 975, "count": "1 through 10" } ], "minimum": 0.01, "maximum": 1000 } ] }, { "description": "N block stellate ganglion", "code_information": [ { "code": "64510", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1605.136042, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1003.210026, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 788.34 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 832.02643 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1083.466828, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 971.1073052, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 786.5166604, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2174.48, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1284.108833, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 968.7202, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 890.29 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 2174.48 } ] }, { "description": "N block inj hypogas plxs", "code_information": [ { "code": "64517", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1605.136042, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1003.210026, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 788.34 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 832.02643 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1083.466828, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 971.1073052, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 786.5166604, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2174.48, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1284.108833, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 968.7202, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 890.29 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 2174.48 } ] }, { "description": "N block lumbar/thoracic", "code_information": [ { "code": "64520", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1605.136042, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1003.210026, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 788.34 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 832.02643 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1083.466828, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 971.1073052, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 786.5166604, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2174.48, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1284.108833, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 968.7202, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 890.29 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 2174.48 } ] }, { "description": "N block inj celiac pelus", "code_information": [ { "code": "64530", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1605.136042, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1003.210026, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 788.34 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 832.02643 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1083.466828, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 971.1073052, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 786.5166604, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2174.48, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1284.108833, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 968.7202, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 890.29 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 2174.48 } ] }, { "description": "Implant neuroelectrodes", "code_information": [ { "code": "64555", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 11565.67281, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7228.545506, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6006.47 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6339.333398 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7806.829146, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6997.23205, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5667.179677, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 16029.49, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9252.538248, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6980.05, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6562.9 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 5667.179677, "maximum": 16029.49 } ] }, { "description": "Implant neuroelectrodes", "code_information": [ { "code": "64561", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 11565.67281, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7228.545506, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6006.47 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6339.333398 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7806.829146, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6997.23205, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5667.179677, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 16029.49, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9252.538248, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6980.05, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6562.9 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 16029.49 } ] }, { "description": "Opn impltj nea perph nerve", "code_information": [ { "code": "64575", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 20221.69793, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12638.56121, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10110.84897, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 288.52, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 18716.46 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 19753.69373 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10110.84897, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 288.52, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13649.6461, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10110.84897, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12234.12725, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9908.631987, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 288.52, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 288.52, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 30457.98, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10110.84897, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16177.35835, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 12204.0772, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10110.84897, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12470.31 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 288.52, "maximum": 30457.98 } ] }, { "description": "Opn impltj nea sacral nerve", "code_information": [ { "code": "64581", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 11565.67281, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7228.545506, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6006.47 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6339.333398 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7806.829146, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6997.23205, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5667.179677, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 16029.49, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9252.538248, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6980.05, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5782.836405, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6562.9 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 16029.49 } ] }, { "description": "Rev/rmv perph nstim eltrd ra", "code_information": [ { "code": "64585", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6344.713066, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3965.445666, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3056.56 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3225.9531 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4282.681319, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3838.551405, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3108.909402, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8399.58, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5075.770452, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3829.1246, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3439.01 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 8399.58 } ] }, { "description": "Ins/rpl prph sac/gstr npg/r", "code_information": [ { "code": "64590", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 35207.21306, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22004.50816, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17603.60653, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 18716.46 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 19753.69373 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17603.60653, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 23764.86881, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17603.60653, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21300.3639, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17251.5344, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 52376.64, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17603.60653, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 28165.77045, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 21248.0464, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17603.60653, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 21444.39 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 52376.64 } ] }, { "description": "Rev/rmv prph sac/gstr npg/r", "code_information": [ { "code": "64595", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6344.713066, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3965.445666, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3056.56 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3225.9531 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4282.681319, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3838.551405, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3108.909402, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8399.58, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5075.770452, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3829.1246, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3439.01 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 8399.58 } ] }, { "description": "Revj/rmvl nea pn w/int nstim", "code_information": [ { "code": "64598", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6344.713066, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3965.445666, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3636.22 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3321.65 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4282.681319, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3838.551405, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3108.909402, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8399.58, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5075.770452, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3829.1246, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3172.356533, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3439.01 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 8399.58 } ] }, { "description": "Injection treatment of nerve", "code_information": [ { "code": "64620", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1605.136042, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1003.210026, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 788.34 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 832.02643 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1083.466828, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 971.1073052, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 786.5166604, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2174.48, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1284.108833, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 968.7202, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 890.29 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 2174.48 } ] }, { "description": "Dstrj nulyt agt gnclr nrv", "code_information": [ { "code": "64624", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3543.793926, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2214.871204, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1669.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1761.64601 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2392.0609, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2143.995325, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1736.459024, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4769.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2835.035141, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2138.7324, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 4769.52 } ] }, { "description": "Rf abltj nrv nrvtg si jt", "code_information": [ { "code": "64625", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3543.793926, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2214.871204, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1669.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1761.64601 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2392.0609, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2143.995325, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1736.459024, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4769.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2835.035141, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2138.7324, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 4769.52 } ] }, { "description": "Trml dstrj ios bvn 1st 2 l/s", "code_information": [ { "code": "64628", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23299.56312, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14562.22695, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11553.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12193.46747 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15727.20511, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14096.23569, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11416.78593, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 31426.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18639.6505, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14061.6182, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11649.78156, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12866.82 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 31426.44 } ] }, { "description": "Destroy cerv/thor facet jnt", "code_information": [ { "code": "64633", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3543.793926, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2214.871204, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1669.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1761.64601 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2392.0609, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2143.995325, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1736.459024, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4769.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2835.035141, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2138.7324, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1952.77 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 975, "10th_percentile": 975, "90th_percentile": 2924.1, "count": "12" } ], "minimum": 1669.14, "maximum": 4769.52 } ] }, { "description": "Destroy c/th facet jnt addl", "code_information": [ { "code": "64634", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 975, "10th_percentile": 0.45, "90th_percentile": 975, "count": "22" } ], "minimum": 0.01, "maximum": 4500 } ] }, { "description": "Destroy lumb/sac facet jnt", "code_information": [ { "code": "64635", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3543.793926, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2214.871204, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1669.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1761.64601 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2392.0609, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2143.995325, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1736.459024, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "median_amount": 1029, "10th_percentile": 1029, "90th_percentile": 1029, "count": "1 through 10", "additional_payer_notes": "paid via surg time charge" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4769.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2835.035141, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2138.7324, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1952.77 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 6112, "10th_percentile": 5778, "90th_percentile": 6445, "count": "1 through 10" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 975, "10th_percentile": 975, "90th_percentile": 975, "count": "1 through 10" } ], "minimum": 1669.14, "maximum": 4769.52 } ] }, { "description": "Destroy l/s facet jnt addl", "code_information": [ { "code": "64636", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "median_amount": 1029, "10th_percentile": 1029, "90th_percentile": 1029, "count": "12", "additional_payer_notes": "paid via surg time charge" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 6112, "10th_percentile": 5778, "90th_percentile": 6445, "count": "1 through 10" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "median_amount": 975, "10th_percentile": 975, "90th_percentile": 975, "count": "13" } ], "minimum": 0.01, "maximum": 4500 } ] }, { "description": "Injection treatment of nerve", "code_information": [ { "code": "64640", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1605.136042, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1003.210026, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 788.34 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 832.02643 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1083.466828, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 971.1073052, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 786.5166604, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2174.48, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1284.108833, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 968.7202, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 802.5680208, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 890.29 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 2174.48 } ] }, { "description": "Chemodenerv trunk musc 1-5", "code_information": [ { "code": "64646", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1281.028694, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 800.642934, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 606.8 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 640.42623 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 864.6943687, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 775.0223601, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 627.7040603, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1691.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1024.822956, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 773.122, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.5143472, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 692.52 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 1691.44 } ] }, { "description": "Revise hand/foot nerve", "code_information": [ { "code": "64704", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3543.793926, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2214.871204, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1669.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1761.64601 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2392.0609, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2143.995325, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1736.459024, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4769.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2835.035141, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2138.7324, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1952.77 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 4769.52 } ] }, { "description": "Revise arm/leg nerve", "code_information": [ { "code": "64708", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3543.793926, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2214.871204, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1669.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1761.64601 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2392.0609, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2143.995325, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1736.459024, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4769.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2835.035141, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2138.7324, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1952.77 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 4769.52 } ] }, { "description": "Revision of sciatic nerve", "code_information": [ { "code": "64712", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3543.793926, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2214.871204, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1669.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1761.64601 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2392.0609, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2143.995325, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1736.459024, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4769.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2835.035141, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2138.7324, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1952.77 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 4769.52 } ] }, { "description": "Revise ulnar nerve at elbow", "code_information": [ { "code": "64718", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3543.793926, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2214.871204, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1669.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1761.64601 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2392.0609, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2143.995325, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1736.459024, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4769.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2835.035141, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2138.7324, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1952.77 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 4769.52 } ] }, { "description": "Revise ulnar nerve at wrist", "code_information": [ { "code": "64719", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3543.793926, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2214.871204, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1669.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1761.64601 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2392.0609, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2143.995325, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1736.459024, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4769.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2835.035141, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2138.7324, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1952.77 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 4769.52 } ] }, { "description": "Carpal tunnel surgery", "code_information": [ { "code": "64721", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3543.793926, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2214.871204, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1669.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1761.64601 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2392.0609, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2143.995325, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1736.459024, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4769.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2835.035141, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2138.7324, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1952.77 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 4769.52 } ] }, { "description": "Relieve pressure on nerve(s)", "code_information": [ { "code": "64722", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3543.793926, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2214.871204, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.335, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1669.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1761.64601 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.335, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2392.0609, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2143.995325, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1736.459024, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.335, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.335, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4769.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2835.035141, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2138.7324, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1952.77 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.335, "maximum": 4769.52 } ] }, { "description": "Internal nerve revision", "code_information": [ { "code": "64727", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 0.01, "maximum": 359.35 } ] }, { "description": "Incision of spinal nerve", "code_information": [ { "code": "64772", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3543.793926, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2214.871204, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1669.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1761.64601 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2392.0609, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2143.995325, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1736.459024, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4769.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2835.035141, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2138.7324, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1952.77 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 4769.52 } ] }, { "description": "Remove skin nerve lesion", "code_information": [ { "code": "64774", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3543.793926, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2214.871204, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1669.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1761.64601 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2392.0609, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2143.995325, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1736.459024, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4769.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2835.035141, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2138.7324, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1952.77 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 4769.52 } ] }, { "description": "Remove limb nerve lesion", "code_information": [ { "code": "64782", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3543.793926, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2214.871204, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1669.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1761.64601 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2392.0609, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2143.995325, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1736.459024, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4769.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2835.035141, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2138.7324, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1952.77 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 4769.52 } ] }, { "description": "Implant nerve end", "code_information": [ { "code": "64787", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 0.01, "maximum": 481.27 } ] }, { "description": "Repair of hand or foot nerve", "code_information": [ { "code": "64834", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6199.605485, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3874.753428, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3099.802742, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5348.15 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5644.531646 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3099.802742, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4184.733702, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3099.802742, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3750.761318, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3037.806688, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 15641.56, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3099.802742, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4959.684388, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3741.5518, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3099.802742, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6404.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 15641.56 } ] }, { "description": "Repair of leg nerve", "code_information": [ { "code": "64840", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 15926.36078, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9953.975486, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5348.15 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5644.531646 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10750.29352, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9635.44827, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7803.916781, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 15641.56, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12741.08862, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 9611.7812, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6404.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 15641.56 } ] }, { "description": "Nrv grf 1strnd arm/leg <4cm", "code_information": [ { "code": "64892", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 15926.36078, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9953.975486, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5348.15 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5644.531646 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10750.29352, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9635.44827, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7803.916781, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 15641.56, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12741.08862, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 9611.7812, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6404.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 15641.56 } ] }, { "description": "Nerve pedicle transfer", "code_information": [ { "code": "64905", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 15926.36078, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9953.975486, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5348.15 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5644.531646 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10750.29352, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9635.44827, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7803.916781, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 15641.56, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12741.08862, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 9611.7812, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6404.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 15641.56 } ] }, { "description": "Nerve repair w/allograft", "code_information": [ { "code": "64910", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 15926.36078, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9953.975486, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5348.15 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5644.531646 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10750.29352, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9635.44827, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7803.916781, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 15641.56, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12741.08862, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 9611.7812, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7963.180389, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6404.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 5348.15, "maximum": 15641.56 } ] }, { "description": "Unlisted px nervous system", "code_information": [ { "code": "64999", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 557.053952, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 348.15872, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 254.13 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 268.209542 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 376.0114176, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 337.017641, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 272.9564365, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 720.98, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 445.6431616, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 336.189, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 278.526976, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 295.19 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 254.13, "maximum": 720.98 } ] }, { "description": "Goniotomy", "code_information": [ { "code": "65820", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 7501.310544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4688.31909, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3750.655272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3706.83 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3912.260918 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3750.655272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5063.384617, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3750.655272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4538.292879, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3675.642167, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 9825.59, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3750.655272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6001.048435, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4527.1492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3750.655272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4022.86 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 359.35, "maximum": 9825.59 } ] }, { "description": "Trluml dil aq o/f can w/o st", "code_information": [ { "code": "66174", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 7501.310544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4688.31909, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3750.655272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3706.83 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3912.260918 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3750.655272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5063.384617, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3750.655272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4538.292879, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3675.642167, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 679.83, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 9825.59, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3750.655272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6001.048435, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4527.1492, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3750.655272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4022.86 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 679.83, "maximum": 9825.59 } ] }, { "description": "Extraction of lens", "code_information": [ { "code": "66940", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 4188.225059, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2617.640662, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2094.11253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1962.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2071.597756 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2094.11253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2827.051915, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2094.11253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2533.876161, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2052.230279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 773.72, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5570.55, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2094.11253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3350.580047, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2527.6552, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2094.11253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2280.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 773.72, "maximum": 5570.55 } ] }, { "description": "Xcapsl ctrc rmvl cplx wo ecp", "code_information": [ { "code": "66982", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 4188.225059, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2617.640662, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2094.11253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 888.07, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1962.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2071.597756 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2094.11253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 888.07, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2827.051915, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2094.11253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2533.876161, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2052.230279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 888.07, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 888.07, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5570.55, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2094.11253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3350.580047, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2527.6552, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2094.11253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2280.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 888.07, "maximum": 5570.55 } ] }, { "description": "Xcapsl ctrc rmvl w/o ecp", "code_information": [ { "code": "66984", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 4188.225059, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2617.640662, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2094.11253, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 888.07, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1962.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2071.597756 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2094.11253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 888.07, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2827.051915, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2094.11253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2533.876161, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2052.230279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 888.07, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 888.07, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5570.55, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2094.11253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3350.580047, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2527.6552, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2094.11253, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2280.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 888.07, "maximum": 5570.55 } ] }, { "description": "Xcapsl ctrc rmvl insj 1+", "code_information": [ { "code": "66991", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 9657.070259, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6035.668912, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4828.53513, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4126.39 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4355.0623 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4828.53513, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6518.522425, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4828.53513, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5842.527507, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4731.964427, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1073.67, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 12602.28, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4828.53513, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7725.656207, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5828.1776, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4828.53513, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5159.71 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 1073.67, "maximum": 12602.28 } ] }, { "description": "Remove eyelid lesion", "code_information": [ { "code": "67800", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 576.0250496, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 360.015656, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 288.0125248, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 262.59 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 277.144054 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 288.0125248, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 388.8169085, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 288.0125248, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 348.495155, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 282.2522743, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 730.12, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 288.0125248, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 460.8200397, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 347.6354, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 288.0125248, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 298.93 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 262.59, "maximum": 730.12 } ] }, { "description": "Remove eyelid lesions", "code_information": [ { "code": "67805", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 576.0250496, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 360.015656, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 288.0125248, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 262.59 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 277.144054 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 288.0125248, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 388.8169085, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 288.0125248, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 348.495155, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 282.2522743, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 730.12, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 288.0125248, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 460.8200397, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 347.6354, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 288.0125248, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 298.93 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 262.59, "maximum": 730.12 } ] }, { "description": "Insj rx elut implt lac canal", "code_information": [ { "code": "68841", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 4314.645754, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2696.653596, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2157.322877, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 58.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 61.957562 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2157.322877, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2912.385884, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2157.322877, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2610.360681, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2114.176419, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "percent of total billed charges", "standard_charge_percentage": 15.54, "count": "0", "additional_payer_notes": "cost to charge ratio" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5698.11, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2157.322877, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3451.716603, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2603.9482, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2157.322877, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2332.96 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 58.7, "maximum": 5698.11 } ] }, { "description": "Create eardrum opening", "code_information": [ { "code": "69436", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2815.804701, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1759.877938, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1309.94 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1382.533764 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1900.668173, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1703.561844, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1379.744303, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 550.32, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3617.94, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2252.643761, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1699.3788, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1407.90235, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1481.28 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 550.32, "maximum": 3617.94 } ] }, { "description": "Myringoplasty", "code_information": [ { "code": "69620", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6016.875446, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3760.547154, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2542.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2683.724534 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4061.390926, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3640.209645, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2948.268969, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 481.27, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7921, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4813.500357, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3631.2724, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3008.437723, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3243.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 481.27, "maximum": 7921 } ] }, { "description": "Microsurgery add-on", "code_information": [ { "code": "69990", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.353, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.353, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.353, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.353, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback" }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 50, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "percent of total billed charges", "standard_charge_percentage": 45, "count": "0", "additional_payer_notes": "no services performed during 15-month lookback during 15-month lookback period" } ], "minimum": 0.01, "maximum": 359.353 } ] }, { "description": "XR EYES FOREIGN BODY", "code_information": [ { "code": "70030", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 234.6, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.00232, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.00232, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.00232, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.00232, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 111.44, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 105.57 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 117.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 105.57 } ], "minimum": 35.00232, "maximum": 215.05 } ] }, { "description": "XR FACIAL BONES MIN 3 VWS", "code_information": [ { "code": "70150", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 256, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.1952, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.1952, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.1952, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.1952, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 121.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 115.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 128 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 115.2 } ], "minimum": 38.1952, "maximum": 259.74 } ] }, { "description": "XR ORBITS MIN 4 VWS", "code_information": [ { "code": "70200", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 240, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 114, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 108 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 120 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 108 } ], "minimum": 35.808, "maximum": 259.74 } ] }, { "description": "XR SKULL FEWER THAN 4 VWS", "code_information": [ { "code": "70250", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 276, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 41.1792, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 41.1792, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 41.1792, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 41.1792, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 131.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 124.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 138 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 124.2 } ], "minimum": 41.1792, "maximum": 259.74 } ] }, { "description": "XR SKULL COMP MIN 4 VWS", "code_information": [ { "code": "70260", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 432, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.4544, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.4544, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.4544, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.4544, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 205.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 194.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 216 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 194.4 } ], "minimum": 64.4544, "maximum": 259.74 } ] }, { "description": "XR NECK SOFT TISSUE", "code_information": [ { "code": "70360", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 303.44, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 45.273248, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 45.273248, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 45.273248, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 45.273248, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 144.13, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 136.548 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 151.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 136.548 } ], "minimum": 45.273248, "maximum": 215.05 } ] }, { "description": "CT HEAD W/O CON", "code_information": [ { "code": "70450", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1587, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 236.7804, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 236.7804, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 236.7804, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 236.7804, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 753.83, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 714.15 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 793.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 714.15 } ], "minimum": 92.96708221, "maximum": 793.5 } ] }, { "description": "CT HEAD W/ CON", "code_information": [ { "code": "70460", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1780, "discounted_cash": 318.316544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.94784, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 265.576, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 176.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 186.702612 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 265.576, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 214.8636672, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 192.5815091, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 155.9751066, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 265.576, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 265.576, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 845.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 434.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 254.6532352, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 192.1094, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 178.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 801 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 890 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 801 } ], "minimum": 155.9751066, "maximum": 890 } ] }, { "description": "CT HEAD W/WO CON", "code_information": [ { "code": "70470", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2054, "discounted_cash": 318.316544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.94784, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 306.4568, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 176.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 186.702612 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 306.4568, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 214.8636672, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 192.5815091, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 155.9751066, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 306.4568, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 306.4568, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 975.65, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 434.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 254.6532352, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 192.1094, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 178.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 924.3 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1027 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 924.3 } ], "minimum": 155.9751066, "maximum": 1027 } ] }, { "description": "CT ORBIT/SELLA/POST FOSSA/EAR W/O CON", "code_information": [ { "code": "70480", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1511.66, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 225.539672, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 225.539672, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 225.539672, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 225.539672, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 718.04, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 680.247 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 755.83 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 680.247 } ], "minimum": 92.96708221, "maximum": 755.83 } ] }, { "description": "CT ORBIT/SELLA/POST FOSSA/EAR W/WO CON", "code_information": [ { "code": "70482", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2011.23, "discounted_cash": 318.316544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.94784, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 300.075516, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 176.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 186.702612 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 300.075516, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 214.8636672, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 192.5815091, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 155.9751066, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 300.075516, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 300.075516, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 955.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 434.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 254.6532352, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 192.1094, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 178.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 905.0535 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1005.615 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 905.0535 } ], "minimum": 155.9751066, "maximum": 1005.615 } ] }, { "description": "CT MAXILLOFACIAL W/O CON", "code_information": [ { "code": "70486", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1929, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 287.8068, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 287.8068, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 287.8068, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 287.8068, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 916.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 868.05 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 964.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 868.05 } ], "minimum": 92.96708221, "maximum": 964.5 } ] }, { "description": "CT MAXILLOFACIAL W/WO CON", "code_information": [ { "code": "70488", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1929, "discounted_cash": 318.316544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.94784, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 287.8068, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 184.33 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 186.702612 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 287.8068, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 214.8636672 }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 192.5815091, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 155.9751066 }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 287.8068, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 287.8068, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 916.275, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 434.8025, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 254.6532352, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 192.11, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 178.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 868.05 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 964.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 868.05 } ], "minimum": 155.9751066, "maximum": 964.5 } ] }, { "description": "CT SOFT TISSUE NECK W/O CON", "code_information": [ { "code": "70490", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1881.17, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 280.670564, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 280.670564, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 280.670564, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 280.670564, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 893.56, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 846.5265 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 940.585 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 846.5265 } ], "minimum": 92.96708221, "maximum": 940.585 } ] }, { "description": "CT SOFT TISSUE NECK W/ CON", "code_information": [ { "code": "70491", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1677.27, "discounted_cash": 318.316544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.94784, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 250.248684, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 176.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 186.702612 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 250.248684, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 214.8636672, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 192.5815091, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 155.9751066, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 250.248684, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 250.248684, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 796.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 434.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 254.6532352, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 192.1094, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 178.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 754.7715 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 838.635 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 754.7715 } ], "minimum": 155.9751066, "maximum": 838.635 } ] }, { "description": "CT SOFT TISSUE NECK W/WO CON", "code_information": [ { "code": "70492", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1881.17, "discounted_cash": 318.316544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.94784, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 280.670564, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 176.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 186.702612 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 280.670564, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 214.8636672, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 192.5815091, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 155.9751066, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 280.670564, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 280.670564, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 893.56, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 434.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 254.6532352, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 192.1094, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 178.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 846.5265 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 940.585 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 846.5265 } ], "minimum": 155.9751066, "maximum": 940.585 } ] }, { "description": "CTA HEAD WWO/ AND PP", "code_information": [ { "code": "70496", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1809, "discounted_cash": 318.316544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.94784, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 269.9028, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 176.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 186.702612 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 269.9028, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 214.8636672, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 192.5815091, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 155.9751066, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 269.9028, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 269.9028, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 859.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 434.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 254.6532352, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 192.1094, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 178.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 814.05 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 904.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 814.05 } ], "minimum": 155.9751066, "maximum": 904.5 } ] }, { "description": "CTA HEAD W/ AND PP", "code_information": [ { "code": "70496", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1809, "discounted_cash": 318.316544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.94784, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 269.9028, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 176.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 186.702612 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 269.9028, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 214.8636672, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 192.5815091, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 155.9751066, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 269.9028, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 269.9028, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 859.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 434.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 254.6532352, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 192.1094, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 178.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 814.05 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 904.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 814.05 } ], "minimum": 155.9751066, "maximum": 904.5 } ] }, { "description": "CTA NECK W/ AND PP", "code_information": [ { "code": "70498", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2410, "discounted_cash": 318.316544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.94784, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 176.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 186.702612 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 214.8636672, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 192.5815091, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 155.9751066, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1144.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 434.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 254.6532352, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 192.1094, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 178.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1084.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1205 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1084.5 } ], "minimum": 155.9751066, "maximum": 1205 } ] }, { "description": "CTA NECK WWO/ AND PP", "code_information": [ { "code": "70498", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2410, "discounted_cash": 318.316544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.94784, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 176.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 186.702612 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 214.8636672, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 192.5815091, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 155.9751066, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1144.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 434.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 254.6532352, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 192.1094, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 178.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1084.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1205 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1084.5 } ], "minimum": 155.9751066, "maximum": 1205 } ] }, { "description": "MRI ORBIT/FACE/NECK W/O CON", "code_information": [ { "code": "70540", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2958, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 441.3336, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 441.3336, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 212.1766279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 441.3336, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 441.3336, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1405.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 590.4, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.3268, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1331.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1479 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1331.1 } ], "minimum": 212.1766279, "maximum": 1479 } ] }, { "description": "MRI ORBIT/FACE/NECK W/ CON", "code_information": [ { "code": "70542", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2958, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 441.3336, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 441.3336, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 441.3336, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 441.3336, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1405.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1331.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1479 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1331.1 } ], "minimum": 310.2355314, "maximum": 1479 } ] }, { "description": "MRI ORBIT/FACE/NECK W/WO CON", "code_information": [ { "code": "70543", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3058, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 475.2132, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 475.2132, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 475.2132, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 475.2132, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1452.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1376.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1529 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1376.1 } ], "minimum": 310.2355314, "maximum": 1529 } ] }, { "description": "MRA HEAD W/O CON", "code_information": [ { "code": "70544", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2102, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 313.6184, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 313.6184, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 212.1766279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 313.6184, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 313.6184, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 998.45, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 590.4, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.3268, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 945.9 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1051 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 945.9 } ], "minimum": 212.1766279, "maximum": 1051 } ] }, { "description": "MRA NECK W/O CON", "code_information": [ { "code": "70547", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2102, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 313.6184, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 313.6184, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 212.1766279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 313.6184, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 313.6184, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 998.45, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 590.4, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.3268, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 945.9 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1051 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 945.9 } ], "minimum": 212.1766279, "maximum": 1051 } ] }, { "description": "MRI BRAIN/STEM W/O CON", "code_information": [ { "code": "70551", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2281, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 340.3252, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 340.3252, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 212.1766279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 340.3252, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 340.3252, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1083.48, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 590.4, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.3268, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1026.45 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1140.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1026.45 } ], "minimum": 212.1766279, "maximum": 1140.5 } ] }, { "description": "MRI BRAIN/STEM W/WO CON", "code_information": [ { "code": "70553", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3668, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 547.2656, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 547.2656, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 547.2656, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 547.2656, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1742.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1650.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1834 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1650.6 } ], "minimum": 310.2355314, "maximum": 1834 } ] }, { "description": "XR CHEST 1 VW", "code_information": [ { "code": "71045", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 220, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 32.824, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 32.824, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 32.824, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 32.824, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 104.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 99 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 110 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 99 } ], "minimum": 32.824, "maximum": 215.05 } ] }, { "description": "XR CHEST PA AND LATERAL", "code_information": [ { "code": "71046", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 286, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.6712, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.6712, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.6712, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.6712, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 135.85, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 128.7 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 143 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 128.7 } ], "minimum": 42.6712, "maximum": 215.05 } ] }, { "description": "X-ray exam chest 2 views", "code_information": [ { "code": "71046", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 286, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.6712, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.6712, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.6712, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.6712, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 135.85, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.06, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 128.7 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 143 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 128.7 } ], "minimum": 42.6712, "maximum": 215.06 } ] }, { "description": "XR CHEST 2 VWS W/ OBLI", "code_information": [ { "code": "71047", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 416, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 62.0672, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 62.0672, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 62.0672, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 62.0672, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 187.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 208 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 187.2 } ], "minimum": 62.0672, "maximum": 215.05 } ] }, { "description": "XR RIBS LT 2 VWS", "code_information": [ { "code": "71100", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 429, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.0068, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.0068, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.0068, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.0068, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 203.78, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 193.05 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 214.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 193.05 } ], "minimum": 64.0068, "maximum": 215.05 } ] }, { "description": "XR RIBS BILAT W/ PA CHEST MIN 4 VWS", "code_information": [ { "code": "71111", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 415, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 61.918, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 61.918, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 61.918, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 61.918, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.13, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 186.75 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 207.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 186.75 } ], "minimum": 61.918, "maximum": 259.74 } ] }, { "description": "CT THORAX W/O CON", "code_information": [ { "code": "71250", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2925, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 436.41, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 436.41, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 436.41, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 436.41, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1389.38, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1316.25 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1462.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1316.25 } ], "minimum": 92.96708221, "maximum": 1462.5 } ] }, { "description": "CT THORAX W/ CON", "code_information": [ { "code": "71260", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5993.15, "discounted_cash": 318.316544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.94784, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 894.17798, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 176.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 186.702612 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 894.17798, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 214.8636672, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 192.5815091, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 155.9751066, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 894.17798, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 894.17798, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2846.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 434.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 254.6532352, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 192.1094, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 178.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2696.9175 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2996.575 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2696.9175 } ], "minimum": 155.9751066, "maximum": 2996.575 } ] }, { "description": "CT THORAX W/WO CON", "code_information": [ { "code": "71270", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3772, "discounted_cash": 318.316544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.94784, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 562.7824, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 176.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 186.702612 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 562.7824, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 214.8636672, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 192.5815091, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 155.9751066, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 562.7824, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 562.7824, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1791.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 434.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 254.6532352, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 192.1094, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 178.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1697.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1886 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1697.4 } ], "minimum": 155.9751066, "maximum": 1886 } ] }, { "description": "CT CHEST LOW DOSE W/O CONT", "code_information": [ { "code": "71271", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2000, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 298.4, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 298.4, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 298.4, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 298.4, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 950, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 900 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 900 } ], "minimum": 77.48, "maximum": 1000 } ] }, { "description": "CTA CHEST W/ AND PP", "code_information": [ { "code": "71275", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2890, "discounted_cash": 318.316544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.94784, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 431.188, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 176.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 186.702612 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 431.188, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 214.8636672, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 192.5815091, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 155.9751066, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 431.188, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 431.188, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1372.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 434.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 254.6532352, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 192.1094, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 178.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1300.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1445 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1300.5 } ], "minimum": 155.9751066, "maximum": 1445 } ] }, { "description": "XR SPINE CERVICAL 1 VW", "code_information": [ { "code": "72020", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 372, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 55.5024, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 55.5024, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 55.5024, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 55.5024, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 176.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 167.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 186 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 167.4 } ], "minimum": 55.5024, "maximum": 215.05 } ] }, { "description": "XR SPINE THORACIC 1 VW", "code_information": [ { "code": "72020", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 330, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 49.236, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 49.236, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 49.236, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 49.236, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 156.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 148.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 165 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 148.5 } ], "minimum": 49.236, "maximum": 215.05 } ] }, { "description": "XR SPINE CERVICAL 3 VWS OR LESS", "code_information": [ { "code": "72040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 435, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.902, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.902, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.902, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.902, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 206.63, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 195.75 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 217.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 195.75 } ], "minimum": 64.902, "maximum": 217.5 } ] }, { "description": "X-ray exam neck spine 2-3 vw", "code_information": [ { "code": "72040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 435, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.902, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.902, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.902, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.902, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 206.63, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.06, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 195.75 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 217.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 195.75 } ], "minimum": 64.902, "maximum": 217.5 } ] }, { "description": "X-ray exam neck spine 4/5vws", "code_information": [ { "code": "72050", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 576, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 85.9392, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 85.9392, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 85.9392, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 85.9392, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 273.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.73, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 259.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 288 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 259.2 } ], "minimum": 85.9392, "maximum": 288 } ] }, { "description": "XR SPINE CERVICAL 4 OR 5 VWS", "code_information": [ { "code": "72050", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 576, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 85.9392, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 85.9392, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 85.9392, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 85.9392, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 273.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 259.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 288 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 259.2 } ], "minimum": 85.9392, "maximum": 288 } ] }, { "description": "XR SPINE CERVICAL W/ FLEX/ EXT", "code_information": [ { "code": "72052", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 566, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 84.4472, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 84.4472, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 84.4472, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 84.4472, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 268.85, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 254.7 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 283 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 254.7 } ], "minimum": 84.4472, "maximum": 283 } ] }, { "description": "XR SPINE THORACIC 2 VWS", "code_information": [ { "code": "72070", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 435, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.902, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.902, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.902, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.902, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 206.63, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 195.75 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 217.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 195.75 } ], "minimum": 64.902, "maximum": 259.74 } ] }, { "description": "XR SPINE THORACIC 3 VWS", "code_information": [ { "code": "72072", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 534, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 79.6728, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 79.6728, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 79.6728, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 79.6728, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 253.65, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 240.3 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 267 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 240.3 } ], "minimum": 79.6728, "maximum": 267 } ] }, { "description": "X-ray exam thorac spine4/>vw", "code_information": [ { "code": "72074", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 635, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 94.742, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 94.742, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 94.742, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 94.742, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 301.63, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.73, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 285.75 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 317.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 285.75 } ], "minimum": 92.96708221, "maximum": 317.5 } ] }, { "description": "XR SPINE THORACIC 4 VW", "code_information": [ { "code": "72074", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 635, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 94.742, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 94.742, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 94.742, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 94.742, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 301.63, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 285.75 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 317.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 285.75 } ], "minimum": 92.96708221, "maximum": 317.5 } ] }, { "description": "XR SPINE THORACOLUMBAR 2 VWS", "code_information": [ { "code": "72080", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 288, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.9696, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.9696, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.9696, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.9696, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 136.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 129.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 144 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 129.6 } ], "minimum": 42.9696, "maximum": 215.05 } ] }, { "description": "XR SPINE LUMBOSACRAL 2 OR 3 VWS", "code_information": [ { "code": "72100", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 424, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 63.2608, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 63.2608, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 63.2608, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 63.2608, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 201.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 190.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 212 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 190.8 } ], "minimum": 63.2608, "maximum": 259.74 } ] }, { "description": "X-ray exam l-2 spine 4/>vws", "code_information": [ { "code": "72110", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 581, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 86.6852, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 86.6852, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 86.6852, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 86.6852, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 275.98, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.73, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 261.45 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 290.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 261.45 } ], "minimum": 86.6852, "maximum": 290.5 } ] }, { "description": "XR SPINE LUMBOSACRAL MIN 4 VWS", "code_information": [ { "code": "72110", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 581, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 86.6852, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 86.6852, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 86.6852, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 86.6852, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 275.98, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 261.45 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 290.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 261.45 } ], "minimum": 86.6852, "maximum": 290.5 } ] }, { "description": "XR SPINE LS COMP W/ BEND VWS MIN 6 VWS", "code_information": [ { "code": "72114", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 303.44, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 45.273248, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 45.273248, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 45.273248, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 45.273248, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 144.13, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 136.548 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 151.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 136.548 } ], "minimum": 45.273248, "maximum": 259.74 } ] }, { "description": "X-ray bend only l-s spine", "code_information": [ { "code": "72120", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 378, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 56.3976, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 56.3976, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 56.3976, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 56.3976, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 179.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.73, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 170.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 189 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 170.1 } ], "minimum": 56.3976, "maximum": 259.73 } ] }, { "description": "XR SPINE LS BEND VWS ONLY 2 OR 3 VWS", "code_information": [ { "code": "72120", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 378, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 56.3976, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 56.3976, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 56.3976, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 56.3976, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 179.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 170.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 189 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 170.1 } ], "minimum": 56.3976, "maximum": 259.74 } ] }, { "description": "CT SPINE CERVICAL W/O CON", "code_information": [ { "code": "72125", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1778, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 265.2776, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 265.2776, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 265.2776, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 265.2776, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 844.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 800.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 889 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 800.1 } ], "minimum": 92.96708221, "maximum": 889 } ] }, { "description": "CT SPINE CERVICAL W/ CON", "code_information": [ { "code": "72126", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1594, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 237.8248, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 237.8248, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 237.8248, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 237.8248, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 757.15, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 717.3 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 797 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 717.3 } ], "minimum": 237.8248, "maximum": 872.27 } ] }, { "description": "Ct neck spine w/o & w/dye", "code_information": [ { "code": "72127", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1778, "discounted_cash": 318.316544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.94784, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 265.2776, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 176.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 186.702612 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 265.2776, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 214.8636672, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 192.5815091, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 155.9751066, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 265.2776, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 265.2776, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 844.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 434.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 254.6532352, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 192.1094, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 178.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 800.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 889 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 800.1 } ], "minimum": 155.9751066, "maximum": 889 } ] }, { "description": "CT SPINE THORACIC W/O CON", "code_information": [ { "code": "72128", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1492, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 222.6064, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 222.6064, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 222.6064, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 222.6064, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 708.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 671.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 746 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 671.4 } ], "minimum": 92.96708221, "maximum": 746 } ] }, { "description": "CT SPINE THORACIC W/ CON", "code_information": [ { "code": "72129", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1746, "discounted_cash": 318.316544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.94784, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 260.5032, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 176.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 186.702612 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 260.5032, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 214.8636672, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 192.5815091, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 155.9751066, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 260.5032, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 260.5032, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 829.35, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 434.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 254.6532352, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 192.1094, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 178.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 785.7 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 873 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 785.7 } ], "minimum": 155.9751066, "maximum": 873 } ] }, { "description": "CT SPINE LUMBAR W/O CON", "code_information": [ { "code": "72131", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1592, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 237.5264, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 237.5264, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 237.5264, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 237.5264, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 756.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 716.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 796 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 716.4 } ], "minimum": 92.96708221, "maximum": 796 } ] }, { "description": "CT SPINE LUMBAR W/ CON", "code_information": [ { "code": "72132", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1616, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 241.1072, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 241.1072, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 241.1072, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 241.1072, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 767.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 727.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 808 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 727.2 } ], "minimum": 241.1072, "maximum": 872.27 } ] }, { "description": "Ct lumbar spine w/dye", "code_information": [ { "code": "72132", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1616, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 241.1072, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 241.1072, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 241.1072, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 241.1072, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 767.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 727.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 808 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 727.2 } ], "minimum": 241.1072, "maximum": 872.27 } ] }, { "description": "CT SPINE LUMBAR W/WO CON", "code_information": [ { "code": "72133", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1778, "discounted_cash": 318.316544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.94784, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 265.2776, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 176.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 186.702612 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 265.2776, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 214.8636672, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 192.5815091, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 155.9751066, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 265.2776, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 265.2776, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 844.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 434.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 254.6532352, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 192.1094, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 178.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 800.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 889 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 800.1 } ], "minimum": 155.9751066, "maximum": 889 } ] }, { "description": "MRI SPINE CERVICAL W/O CON", "code_information": [ { "code": "72141", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2138, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 318.9896, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 318.9896, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 212.1766279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 318.9896, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 318.9896, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1015.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 590.4, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.3268, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 962.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1069 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 962.1 } ], "minimum": 212.1766279, "maximum": 1069 } ] }, { "description": "MRI SPINE THORACIC W/O CON", "code_information": [ { "code": "72146", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2063, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 307.7996, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 307.7996, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 212.1766279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 307.7996, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 307.7996, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 979.93, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 590.4, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.3268, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 928.35 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1031.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 928.35 } ], "minimum": 212.1766279, "maximum": 1031.5 } ] }, { "description": "Mri chest spine w/o dye", "code_information": [ { "code": "72146", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2063, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 307.7996, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 307.7996, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 212.1766279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 307.7996, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 307.7996, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 979.93, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 590.39, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.3268, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 928.35 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1031.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 928.35 } ], "minimum": 212.1766279, "maximum": 1031.5 } ] }, { "description": "Mri lumbar spine w/o dye", "code_information": [ { "code": "72148", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2147, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 320.3324, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 320.3324, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 212.1766279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 320.3324, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 320.3324, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1019.83, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 590.39, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.3268, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 966.15 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1073.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 966.15 } ], "minimum": 212.1766279, "maximum": 1073.5 } ] }, { "description": "MRI SPINE LUMBAR W/O CON", "code_information": [ { "code": "72148", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2147, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 320.3324, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 320.3324, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 212.1766279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 320.3324, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 320.3324, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1019.83, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.3268, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 966.15 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1073.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 966.15 } ], "minimum": 212.1766279, "maximum": 1073.5 } ] }, { "description": "MRI SPINE CERVICAL W/WO CON", "code_information": [ { "code": "72156", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3016, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 449.9872, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 449.9872, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 449.9872, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 449.9872, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1432.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1357.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1508 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1357.2 } ], "minimum": 310.2355314, "maximum": 1508 } ] }, { "description": "MRI SPINE THORACIC W/WO CON", "code_information": [ { "code": "72157", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3538, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 527.8696, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 527.8696, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 527.8696, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 527.8696, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1680.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1592.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1769 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1592.1 } ], "minimum": 310.2355314, "maximum": 1769 } ] }, { "description": "MRI SPINE LUMBAR W/WO CON", "code_information": [ { "code": "72158", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3665, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 546.818, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 546.818, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 546.818, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 546.818, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1740.88, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1649.25 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1832.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1649.25 } ], "minimum": 310.2355314, "maximum": 1832.5 } ] }, { "description": "XR PELVIS 1 OR 2 VWS", "code_information": [ { "code": "72170", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 288, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.9696, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.9696, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.9696, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.9696, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 136.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 129.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 144 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 129.6 } ], "minimum": 42.9696, "maximum": 259.74 } ] }, { "description": "CT PELVIS W/O CON", "code_information": [ { "code": "72192", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1490, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 222.308, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 222.308, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 222.308, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 222.308, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 707.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 670.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 745 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 670.5 } ], "minimum": 92.96708221, "maximum": 745 } ] }, { "description": "Ct pelvis w/o dye", "code_information": [ { "code": "72192", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1490, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 222.308, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 222.308, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 222.308, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 222.308, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 707.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.73, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 670.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 745 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 670.5 } ], "minimum": 92.96708221, "maximum": 745 } ] }, { "description": "CT PELVIS W/WO CON", "code_information": [ { "code": "72194", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1893, "discounted_cash": 318.316544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.94784, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 282.4356, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 176.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 186.702612 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 282.4356, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 214.8636672, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 192.5815091, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 155.9751066, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 282.4356, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 282.4356, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 899.18, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 434.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 254.6532352, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 192.1094, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 178.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 851.85 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 946.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 851.85 } ], "minimum": 155.9751066, "maximum": 946.5 } ] }, { "description": "MRI PELVIS W/O CON", "code_information": [ { "code": "72195", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2024, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 301.9808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 301.9808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 212.1766279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 301.9808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 301.9808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 961.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 590.4, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.3268, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 910.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1012 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 910.8 } ], "minimum": 212.1766279, "maximum": 1012 } ] }, { "description": "MRI PELVIS W/WO CON", "code_information": [ { "code": "72197", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3731, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 556.6652, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 556.6652, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 556.6652, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 556.6652, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1772.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 982.11, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1678.95 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1865.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1678.95 } ], "minimum": 310.2355314, "maximum": 1865.5 } ] }, { "description": "XR SI JOINTS MIN 3 VWS", "code_information": [ { "code": "72202", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 251, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.4492, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.4492, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.4492, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.4492, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 119.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 112.95 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 125.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 112.95 } ], "minimum": 37.4492, "maximum": 259.74 } ] }, { "description": "XR SACRUM/ COCCYX MIN 2 VWS", "code_information": [ { "code": "72220", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 310, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 46.252, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 46.252, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 46.252, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 46.252, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 147.25, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 139.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 155 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 139.5 } ], "minimum": 46.252, "maximum": 215.05 } ] }, { "description": "X-ray of lower spine disk", "code_information": [ { "code": "72295", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1877, "discounted_cash": 3543.793926, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2214.871204, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 280.0484, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1669.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1761.64601 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 280.0484, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2392.0609, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2143.995325, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1736.459024, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 280.0484, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 280.0484, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 891.58, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4769.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2835.035141, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2138.7324, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1771.896963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1952.77 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 844.65 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 844.65 } ], "minimum": 280.0484, "maximum": 5000 } ] }, { "description": "XR SCAPULA RT", "code_information": [ { "code": "73010", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 180, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 26.856, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 26.856, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 26.856, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 26.856, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 85.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 81 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 90 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 81 } ], "minimum": 26.856, "maximum": 259.74 } ] }, { "description": "XR SCAPULA LT", "code_information": [ { "code": "73010", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 180, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 26.856, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 26.856, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 26.856, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 26.856, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 85.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 81 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 90 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 81 } ], "minimum": 26.856, "maximum": 259.74 } ] }, { "description": "XR SHOULDER LT COMP MIN 2 VWS", "code_information": [ { "code": "73020", "type": "CPT" }, { "code": "320", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 249, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.1508, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 80.74 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.1508, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126 }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056 }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.1508, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.1508, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 118.275, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 112.05 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 124.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 112.05 } ], "minimum": 37.1508, "maximum": 215.05 } ] }, { "description": "XR SHOULDER RT COMP MIN 2 VWS", "code_information": [ { "code": "73030", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 249, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.1508, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.1508, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.1508, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.1508, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 118.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 112.05 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 124.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 112.05 } ], "minimum": 37.1508, "maximum": 215.05 } ] }, { "description": "X-ray exam of shoulder", "code_information": [ { "code": "73030", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 249, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.1508, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.1508, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.1508, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.1508, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 118.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 112.05 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 124.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 112.05 } ], "minimum": 37.1508, "maximum": 215.05 } ] }, { "description": "XR SHOULDER LT COMP MIN 2 VWS", "code_information": [ { "code": "73030", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 249, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.1508, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.1508, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.1508, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.1508, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 118.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 112.05 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 124.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 112.05 } ], "minimum": 37.1508, "maximum": 215.05 } ] }, { "description": "Contrast x-ray of shoulder", "code_information": [ { "code": "73040", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 249, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.1508, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.1508, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.1508, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.1508, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 118.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 112.05 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 124.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 112.05 } ], "minimum": 37.1508, "maximum": 872.27 } ] }, { "description": "XR HUMERUS RT MIN 2 VWS", "code_information": [ { "code": "73060", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 253, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.7476, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.7476, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.7476, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.7476, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 120.18, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 113.85 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 126.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 113.85 } ], "minimum": 37.7476, "maximum": 215.05 } ] }, { "description": "XR ELBOW RT 2 VWS", "code_information": [ { "code": "73070", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 156, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 23.2752, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 23.2752, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 23.2752, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 23.2752, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 74.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 70.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 78 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 70.2 } ], "minimum": 23.2752, "maximum": 215.05 } ] }, { "description": "XR ELBOW RT COMP MIN 3 VWS", "code_information": [ { "code": "73080", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 251, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.4492, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.4492, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.4492, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.4492, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 119.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 112.95 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 125.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 112.95 } ], "minimum": 37.4492, "maximum": 215.05 } ] }, { "description": "XR ELBOW LT COMP MIN 3 VWS", "code_information": [ { "code": "73080", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 251, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.4492, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.4492, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.4492, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.4492, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 119.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 112.95 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 125.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 112.95 } ], "minimum": 37.4492, "maximum": 215.05 } ] }, { "description": "XR FOREARM RT 2 VWS", "code_information": [ { "code": "73090", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 251, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.4492, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.4492, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.4492, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 37.4492, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 119.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 112.95 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 125.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 112.95 } ], "minimum": 37.4492, "maximum": 215.05 } ] }, { "description": "XR WRIST LT MIN 3 VWS", "code_information": [ { "code": "73110", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 258, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.4936, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.4936, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.4936, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.4936, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 122.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 116.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 129 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 116.1 } ], "minimum": 38.4936, "maximum": 215.05 } ] }, { "description": "XR WRIST RT MIN 3 VWS", "code_information": [ { "code": "73110", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 258, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.4936, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.4936, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.4936, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.4936, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 122.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 116.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 129 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 116.1 } ], "minimum": 38.4936, "maximum": 215.05 } ] }, { "description": "XR HAND LT 2 VWS", "code_information": [ { "code": "73120", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 142, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 21.1864, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 21.1864, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 21.1864, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 21.1864, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 67.45, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 63.9 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 71 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 63.9 } ], "minimum": 21.1864, "maximum": 259.74 } ] }, { "description": "XR HAND RT 2 VWS", "code_information": [ { "code": "73120", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 142, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 21.1864, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 21.1864, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 21.1864, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 21.1864, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 67.45, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 63.9 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 71 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 63.9 } ], "minimum": 21.1864, "maximum": 259.74 } ] }, { "description": "XR HAND LT COMP MIN 3 VWS", "code_information": [ { "code": "73130", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 240, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 114, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 108 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 120 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 108 } ], "minimum": 35.808, "maximum": 215.05 } ] }, { "description": "XR HAND RT COMP MIN 3 VWS", "code_information": [ { "code": "73130", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 240, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 114, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 108 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 120 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 108 } ], "minimum": 35.808, "maximum": 215.05 } ] }, { "description": "XR FINGER(S) LT MIN 2 VWS", "code_information": [ { "code": "73140", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 240, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 114, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 108 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 120 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 108 } ], "minimum": 35.808, "maximum": 215.05 } ] }, { "description": "Ct upper extremity w/o dye", "code_information": [ { "code": "73200", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 773, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 115.3316, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 115.3316, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 115.3316, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 115.3316, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 367.18, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.73, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 347.85 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 386.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 347.85 } ], "minimum": 92.96708221, "maximum": 386.5 } ] }, { "description": "CT UPP EXT RT W/O CON", "code_information": [ { "code": "73200", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 773.19, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 115.359948, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 115.359948, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 115.359948, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 115.359948, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 367.27, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 347.9355 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 386.595 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 347.9355 } ], "minimum": 92.96708221, "maximum": 386.595 } ] }, { "description": "CT UPP EXT LT W/O CON", "code_information": [ { "code": "73200", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2820.46, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 420.812632, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 420.812632, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 420.812632, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 420.812632, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1339.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1269.207 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1410.23 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1269.207 } ], "minimum": 92.96708221, "maximum": 1410.23 } ] }, { "description": "CT UPP EXT LT W/ CON", "code_information": [ { "code": "73201", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1644.28, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 245.326576, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 386.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 245.326576, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729 }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688 }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 245.326576, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 245.326576, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 781.033, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.2725, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 739.926 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 822.14 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 739.926 } ], "minimum": 245.326576, "maximum": 872.2725 } ] }, { "description": "MRI UPP EXT NOT JT RT W/O CON", "code_information": [ { "code": "73218", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2024, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 301.9808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 301.9808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 212.1766279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 301.9808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 301.9808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 961.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 590.4, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.3268, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 910.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1012 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 910.8 } ], "minimum": 212.1766279, "maximum": 1012 } ] }, { "description": "MRI UPP EXT NOT JT RT W/WO CON", "code_information": [ { "code": "73220", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3352, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 500.1184, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 500.1184, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 500.1184, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 500.1184, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1592.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1508.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1676 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1508.4 } ], "minimum": 310.2355314, "maximum": 1676 } ] }, { "description": "Mri joint upr extrem w/o dye", "code_information": [ { "code": "73221", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2421, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 361.2132, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 361.2132, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 212.1766279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 361.2132, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 361.2132, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1149.98, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 590.39, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.3268, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1089.45 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1210.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1089.45 } ], "minimum": 212.1766279, "maximum": 1210.5 } ] }, { "description": "MRI UPP EXT JT RT W/O CON", "code_information": [ { "code": "73221", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2421, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 361.2132, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 361.2132, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 212.1766279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 361.2132, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 361.2132, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1149.98, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 590.4, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.3268, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1089.45 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1210.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1089.45 } ], "minimum": 212.1766279, "maximum": 1210.5 } ] }, { "description": "MRI UPP EXT JT LT W/O CON", "code_information": [ { "code": "73221", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2421, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 361.2132, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 361.2132, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 212.1766279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 361.2132, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 361.2132, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1149.98, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 590.4, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.3268, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1089.45 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1210.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1089.45 } ], "minimum": 212.1766279, "maximum": 1210.5 } ] }, { "description": "MRI UPP EXT JT LT W/ CON", "code_information": [ { "code": "73222", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2491, "discounted_cash": 1422.654688, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 889.15918, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 371.6572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 660.94 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 697.568172 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 371.6572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 960.2919144, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 860.7060862, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 697.1007971, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 371.6572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 371.6572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1183.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1928.03, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1138.12375, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 858.5878, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 790.06 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1120.95 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1245.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1120.95 } ], "minimum": 371.6572, "maximum": 1928.03 } ] }, { "description": "MRI UPP EXT JT LT W/WO CON", "code_information": [ { "code": "73223", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3371, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 502.9532, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 502.9532, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 502.9532, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 502.9532, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1601.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1516.95 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1685.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1516.95 } ], "minimum": 310.2355314, "maximum": 1685.5 } ] }, { "description": "XR HIP LT 1 VW", "code_information": [ { "code": "73501", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 173, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 25.8116, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 25.8116, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 25.8116, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 25.8116, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.18, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 77.85 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 86.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 77.85 } ], "minimum": 25.8116, "maximum": 215.05 } ] }, { "description": "XR HIP RT 1 VW", "code_information": [ { "code": "73501", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 173, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 25.8116, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 25.8116, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 25.8116, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 25.8116, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.18, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 77.85 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 86.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 77.85 } ], "minimum": 25.8116, "maximum": 215.05 } ] }, { "description": "XR HIP RT COMP MIN 2 VWS", "code_information": [ { "code": "73502", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 232, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 34.6144, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 34.6144, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 34.6144, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 34.6144, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 110.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 104.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 116 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 104.4 } ], "minimum": 34.6144, "maximum": 215.05 } ] }, { "description": "XR HIP LT COMP MIN 2 VWS", "code_information": [ { "code": "73502", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 232, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 34.6144, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 34.6144, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 34.6144, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 34.6144, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 110.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 104.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 116 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 104.4 } ], "minimum": 34.6144, "maximum": 215.05 } ] }, { "description": "XR HIPS BILAT W/ AP PELVIS", "code_information": [ { "code": "73521", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 321, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 47.8932, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 47.8932, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 47.8932, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 47.8932, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.48, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 144.45 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 160.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 144.45 } ], "minimum": 47.8932, "maximum": 259.74 } ] }, { "description": "XR FEMUR LT", "code_information": [ { "code": "73551", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 290, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.268, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.268, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.268, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.268, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 137.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 130.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 145 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 130.5 } ], "minimum": 43.268, "maximum": 215.05 } ] }, { "description": "XR FEMUR RT", "code_information": [ { "code": "73551", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 290, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.268, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.268, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.268, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.268, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 137.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 130.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 145 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 130.5 } ], "minimum": 43.268, "maximum": 215.05 } ] }, { "description": "XR KNEE LT 1 OR 2 VWS", "code_information": [ { "code": "73560", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 268, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 39.9856, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 39.9856, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 39.9856, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 39.9856, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 127.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 120.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 134 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 120.6 } ], "minimum": 39.9856, "maximum": 215.05 } ] }, { "description": "XR KNEE RT 1 OR 2 VWS", "code_information": [ { "code": "73560", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 268, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 39.9856, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 39.9856, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 39.9856, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 39.9856, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 127.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 120.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 134 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 120.6 } ], "minimum": 39.9856, "maximum": 215.05 } ] }, { "description": "XR KNEE RT 3 VWS", "code_information": [ { "code": "73562", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 237, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.3604, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.3604, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.3604, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.3604, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 112.58, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 106.65 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 118.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 106.65 } ], "minimum": 35.3604, "maximum": 215.05 } ] }, { "description": "XR KNEE LT 3 VWS", "code_information": [ { "code": "73562", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 237, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.3604, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.3604, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.3604, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.3604, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 112.58, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 106.65 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 118.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 106.65 } ], "minimum": 35.3604, "maximum": 215.05 } ] }, { "description": "XR KNEE RT COMP MIN 4 VWS", "code_information": [ { "code": "73564", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 286, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.6712, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.6712, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.6712, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.6712, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 135.85, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 128.7 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 143 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 128.7 } ], "minimum": 42.6712, "maximum": 259.74 } ] }, { "description": "XR KNEE LT COMP MIN 4 VWS", "code_information": [ { "code": "73564", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 286, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.6712, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.6712, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.6712, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 42.6712, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 135.85, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 128.7 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 143 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 128.7 } ], "minimum": 42.6712, "maximum": 259.74 } ] }, { "description": "XR TIBIA/ FIBULA LT 2 VWS", "code_information": [ { "code": "73590", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 240, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 114, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 108 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 120 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 108 } ], "minimum": 35.808, "maximum": 215.05 } ] }, { "description": "XR TIBIA/ FIBULA RT 2 VWS", "code_information": [ { "code": "73590", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 240, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 114, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 108 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 120 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 108 } ], "minimum": 35.808, "maximum": 215.05 } ] }, { "description": "XR ANKLE RT 2 VWS", "code_information": [ { "code": "73600", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 206, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 30.7352, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 30.7352, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 30.7352, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 30.7352, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 97.85, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 92.7 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 103 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 92.7 } ], "minimum": 30.7352, "maximum": 215.05 } ] }, { "description": "XR ANKLE LT 2 VWS", "code_information": [ { "code": "73600", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 206, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 30.7352, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 30.7352, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 30.7352, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 30.7352, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 97.85, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 92.7 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 103 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 92.7 } ], "minimum": 30.7352, "maximum": 215.05 } ] }, { "description": "XR ANKLE RT COMP 3 VWS", "code_information": [ { "code": "73610", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 289, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.1188, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.1188, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.1188, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.1188, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 137.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 130.05 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 144.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 130.05 } ], "minimum": 43.1188, "maximum": 215.05 } ] }, { "description": "XR ANKLE LT COMP 3 VWS", "code_information": [ { "code": "73610", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 289, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.1188, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.1188, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.1188, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.1188, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 137.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 130.05 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 144.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 130.05 } ], "minimum": 43.1188, "maximum": 215.05 } ] }, { "description": "XR FOOT RT 2 VWS", "code_information": [ { "code": "73620", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 206, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 30.7352, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 30.7352, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 30.7352, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 30.7352, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 97.85, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 92.7 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 103 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 92.7 } ], "minimum": 30.7352, "maximum": 215.05 } ] }, { "description": "XR FOOT LT 2 VWS", "code_information": [ { "code": "73620", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 206, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 30.7352, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 30.7352, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 30.7352, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 30.7352, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 97.85, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 92.7 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 103 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 92.7 } ], "minimum": 30.7352, "maximum": 215.05 } ] }, { "description": "XR FOOT RT COMP MIN 3 VWS", "code_information": [ { "code": "73630", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 256, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.1952, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.1952, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.1952, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.1952, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 121.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 115.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 128 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 115.2 } ], "minimum": 38.1952, "maximum": 215.05 } ] }, { "description": "XR FOOT LT COMP MIN 3 VWS", "code_information": [ { "code": "73630", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 256, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.1952, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.1952, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.1952, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.1952, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 121.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 115.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 128 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 115.2 } ], "minimum": 38.1952, "maximum": 215.05 } ] }, { "description": "XR TOE(S) RT MIN 2 VWS", "code_information": [ { "code": "73660", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 256, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.1952, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.1952, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.1952, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 38.1952, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 121.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 115.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 128 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 115.2 } ], "minimum": 38.1952, "maximum": 215.05 } ] }, { "description": "CT LOW EXT RT W/O CON", "code_information": [ { "code": "73700", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1475, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 220.07, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 220.07, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 220.07, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 220.07, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 700.63, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 663.75 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 737.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 663.75 } ], "minimum": 92.96708221, "maximum": 737.5 } ] }, { "description": "CT LOW EXT LT W/O CON", "code_information": [ { "code": "73700", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1083, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 161.5836, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 161.5836, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 161.5836, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 161.5836, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 514.43, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 487.35 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 541.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 487.35 } ], "minimum": 92.96708221, "maximum": 541.5 } ] }, { "description": "CT LOW EXT LT W/WO CON", "code_information": [ { "code": "73702", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1475, "discounted_cash": 318.316544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.94784, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 220.07, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 176.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 186.702612 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 220.07, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 214.8636672, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 192.5815091, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 155.9751066, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 220.07, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 220.07, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 700.63, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 434.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 254.6532352, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 192.1094, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 178.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 663.75 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 737.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 663.75 } ], "minimum": 155.9751066, "maximum": 737.5 } ] }, { "description": "MRI LOW EXT NOT JT LT W/O CON", "code_information": [ { "code": "73718", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2024, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 301.9808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 301.9808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 212.1766279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 301.9808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 301.9808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 961.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 590.4, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.3268, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 910.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1012 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 910.8 } ], "minimum": 212.1766279, "maximum": 1012 } ] }, { "description": "MRI LOW EXT NOT JT RT W/O CON", "code_information": [ { "code": "73718", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2024, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 301.9808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 301.9808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 212.1766279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 301.9808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 301.9808, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 961.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 590.4, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.3268, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 910.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1012 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 910.8 } ], "minimum": 212.1766279, "maximum": 1012 } ] }, { "description": "MRI LOW EXT NOT JT RT W/WO CON", "code_information": [ { "code": "73720", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2134, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 318.3928, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 318.3928, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 318.3928, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 318.3928, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1013.65, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 960.3 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1067 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 960.3 } ], "minimum": 310.2355314, "maximum": 1067 } ] }, { "description": "MRI LOW EXT NOT JT LT W/WO CON", "code_information": [ { "code": "73720", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2134, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 318.3928, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 318.3928, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 318.3928, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 318.3928, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1013.65, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 960.3 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1067 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 960.3 } ], "minimum": 310.2355314, "maximum": 1067 } ] }, { "description": "MRI LOW EXT JT LT W/O CON", "code_information": [ { "code": "73721", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2508, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 374.1936, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 374.1936, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 212.1766279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 374.1936, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 374.1936, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1191.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 590.4, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.3268, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1128.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1254 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1128.6 } ], "minimum": 212.1766279, "maximum": 1254 } ] }, { "description": "MRI LOW EXT JT RT W/O CON", "code_information": [ { "code": "73721", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2508, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 374.1936, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 374.1936, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 212.1766279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 374.1936, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 374.1936, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1191.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 590.4, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.3268, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1128.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1254 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1128.6 } ], "minimum": 212.1766279, "maximum": 1254 } ] }, { "description": "Mri joint of lwr extr w/dye", "code_information": [ { "code": "73722", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2491, "discounted_cash": 1422.654688, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 889.15918, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 371.6572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 660.94 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 697.568172 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 371.6572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 960.2919144, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 860.7060862, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 697.1007971, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 371.6572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 371.6572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1183.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1929.67, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1138.12375, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 858.5878, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 790.06 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1120.95 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1245.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1120.95 } ], "minimum": 371.6572, "maximum": 1929.67 } ] }, { "description": "MRI LOW EXT JT LT W/ CON", "code_information": [ { "code": "73722", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2491, "discounted_cash": 1422.654688, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 889.15918, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 371.6572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 660.94 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 697.568172 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 371.6572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 960.2919144, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 860.7060862, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 697.1007971, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 371.6572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 371.6572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1183.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1929.68, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1138.12375, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 858.5878, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 790.06 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1120.95 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1245.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1120.95 } ], "minimum": 371.6572, "maximum": 1929.68 } ] }, { "description": "MRI LOW EXT JT RT W/ CON", "code_information": [ { "code": "73722", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2491, "discounted_cash": 1422.654688, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 889.15918, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 371.6572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 660.94 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 697.568172 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 371.6572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 960.2919144, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 860.7060862, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 697.1007971, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 371.6572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 371.6572, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1183.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1929.68, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1138.12375, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 858.5878, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.327344, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 790.06 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1120.95 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1245.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1120.95 } ], "minimum": 371.6572, "maximum": 1929.68 } ] }, { "description": "MRI LOW EXT JT RT W/WO CON", "code_information": [ { "code": "73723", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3371, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 502.9532, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 502.9532, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 502.9532, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 502.9532, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1601.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1516.95 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1685.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1516.95 } ], "minimum": 310.2355314, "maximum": 1685.5 } ] }, { "description": "MRI LOW EXT JT LT W/WO CON", "code_information": [ { "code": "73723", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3371, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 502.9532, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 502.9532, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 502.9532, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 502.9532, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1601.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1516.95 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1685.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1516.95 } ], "minimum": 310.2355314, "maximum": 1685.5 } ] }, { "description": "XR ABDOMEN 1 VIEW AP", "code_information": [ { "code": "74018", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 275, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 41.03, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 22.77 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 24.02687 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 41.03, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 41.03, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 41.03, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 130.63, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 123.75 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 137.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 123.75 } ], "minimum": 22.77, "maximum": 215.05 } ] }, { "description": "Radex abdomen 3+ views", "code_information": [ { "code": "74021", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 340, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 50.728, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 50.728, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 50.728, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 50.728, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 161.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.73, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 153 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 170 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 153 } ], "minimum": 50.728, "maximum": 259.73 } ] }, { "description": "XR ABD COMP ERECT AND/ OR DECUB", "code_information": [ { "code": "74021", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 340, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 50.728, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 50.728, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 50.728, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 50.728, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 161.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 153 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 170 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 153 } ], "minimum": 50.728, "maximum": 259.74 } ] }, { "description": "XR ACUTE ABD SERIES", "code_information": [ { "code": "74022", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 517, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 77.1364, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 77.1364, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 77.1364, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 77.1364, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 245.58, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 232.65 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 258.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 232.65 } ], "minimum": 77.1364, "maximum": 259.74 } ] }, { "description": "CT ABDOMEN W/O CON", "code_information": [ { "code": "74150", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1347, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 200.9724, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 200.9724, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 200.9724, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 200.9724, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 639.83, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 606.15 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 673.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 606.15 } ], "minimum": 92.96708221, "maximum": 673.5 } ] }, { "description": "CT ABDOMEN W/ CON", "code_information": [ { "code": "74160", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1653, "discounted_cash": 318.316544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.94784, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 246.6276, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 176.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 186.702612 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 246.6276, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 214.8636672, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 192.5815091, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 155.9751066, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 246.6276, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 246.6276, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 785.18, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 434.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 254.6532352, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 192.1094, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 178.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 743.85 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 826.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 743.85 } ], "minimum": 155.9751066, "maximum": 826.5 } ] }, { "description": "CT ABDOMEN W/WO CON", "code_information": [ { "code": "74170", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4166, "discounted_cash": 318.316544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.94784, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 621.5672, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 176.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 186.702612 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 621.5672, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 214.8636672, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 192.5815091, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 155.9751066, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 621.5672, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 621.5672, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1978.85, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 434.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 254.6532352, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 192.1094, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 178.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1874.7 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2083 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1874.7 } ], "minimum": 155.9751066, "maximum": 2083 } ] }, { "description": "CTA ABD/ PEL W/ AND PP", "code_information": [ { "code": "74174", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2007, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 299.4444, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 299.4444, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 299.4444, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 299.4444, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 953.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 903.15 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1003.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 903.15 } ], "minimum": 299.4444, "maximum": 1003.5 } ] }, { "description": "CT ABD/PEL W/O CON", "code_information": [ { "code": "74176", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1674.75, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 249.8727, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 249.8727, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 212.1766279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 249.8727, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 249.8727, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 795.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 590.4, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.3268, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 753.6375 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 837.375 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 753.6375 } ], "minimum": 212.1766279, "maximum": 837.375 } ] }, { "description": "CT ABD/PEL W/ CON", "code_information": [ { "code": "74177", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1199.24, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 178.926608, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 178.926608, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 178.926608, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 178.926608, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 569.64, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 539.658 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 599.62 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 539.658 } ], "minimum": 178.926608, "maximum": 872.27 } ] }, { "description": "CT ABD/PEL W/WO CON", "code_information": [ { "code": "74178", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4166, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 621.5672, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 621.5672, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 621.5672, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 621.5672, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1978.85, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1874.7 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2083 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1874.7 } ], "minimum": 310.2355314, "maximum": 2083 } ] }, { "description": "MRI ABDOMEN W/O CON", "code_information": [ { "code": "74181", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2024, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 301.9808, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 301.9808, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 212.1766279, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 301.9808, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 301.9808, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 961.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 590.4, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.3268, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 910.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1012 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 910.8 } ], "minimum": 212.1766279, "maximum": 1012 } ] }, { "description": "MRI ABDOMEN W/WO CON", "code_information": [ { "code": "74183", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3538, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 527.8696, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 527.8696, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 527.8696, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 527.8696, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1680.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1592.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1769 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1592.1 } ], "minimum": 310.2355314, "maximum": 1769 } ] }, { "description": "Urography iv +-kub tomog", "code_information": [ { "code": "74400", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1109.5, "discounted_cash": 318.316544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.94784, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 165.5374, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 176.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 186.702612 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 165.5374, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 214.8636672, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 192.5815091, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 155.9751066, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 165.5374, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 165.5374, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 527.01, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 434.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 254.6532352, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 192.1094, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 178.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 499.275 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 554.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 499.275 } ], "minimum": 155.9751066, "maximum": 554.75 } ] }, { "description": "XR CYSTOGRAPHY MIN 3 VWS", "code_information": [ { "code": "74430", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 704.48, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 105.108416, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 105.108416, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 105.108416, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 105.108416, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 334.63, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 317.016 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.24 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 317.016 } ], "minimum": 105.108416, "maximum": 872.27 } ] }, { "description": "Contrast x-ray bladder", "code_information": [ { "code": "74430", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 704.48, "discounted_cash": 633.1337376, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 395.708586, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 105.108416, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 370.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 391.24351 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 105.108416, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 427.3652729, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 383.0459112, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 310.2355314, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 105.108416, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 105.108416, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 334.63, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 872.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.5069901, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 382.102, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 316.5668688, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 357.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 317.016 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.24 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 317.016 } ], "minimum": 105.108416, "maximum": 872.27 } ] }, { "description": "CT CALCIUM SCORING", "code_information": [ { "code": "75571", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1199.24, "discounted_cash": 157.9326112, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 98.707882, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 178.926608, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 77.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 81.773326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 178.926608, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.6045126, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 95.54922978, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 77.38697949, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 178.926608, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 178.926608, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 569.64, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 215.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 126.346089, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 95.3148, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 78.9663056, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 88.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 539.658 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 599.62 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 539.658 } ], "minimum": 77.38697949, "maximum": 599.62 } ] }, { "description": "CTA AORTA-ILIOFEMORAL RO W/ AND PP", "code_information": [ { "code": "75635", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1354.12, "discounted_cash": 318.316544, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.94784, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 202.034704, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 176.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 186.702612 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 202.034704, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 214.8636672, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 192.5815091, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 155.9751066, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 202.034704, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 202.034704, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 643.21, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 434.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 254.6532352, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 192.1094, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 159.158272, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 178.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 609.354 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 677.06 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 609.354 } ], "minimum": 155.9751066, "maximum": 677.06 } ] }, { "description": "CT 3D W/O IND IMAGE PP", "code_information": [ { "code": "76376", "type": "CPT" }, { "code": "350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1454.38, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 216.993496, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 16.31 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 16.516552 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 216.993496, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 216.993496, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 216.993496, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 690.8305, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 654.471 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 727.19 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 654.471 } ], "minimum": 16.31, "maximum": 727.19 } ] }, { "description": "US SOFT TISSUE HEAD/NECK", "code_information": [ { "code": "76536", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 760, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 113.392, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 113.392, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 113.392, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 113.392, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 361, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 342 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 380 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 342 } ], "minimum": 92.96708221, "maximum": 380 } ] }, { "description": "US ABDOMEN COMP", "code_information": [ { "code": "76700", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1164, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 173.6688, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 173.6688, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 173.6688, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 173.6688, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 552.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 523.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 582 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 523.8 } ], "minimum": 92.96708221, "maximum": 582 } ] }, { "description": "US ABDOMEN LTD", "code_information": [ { "code": "76705", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 803, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.8076, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.8076, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.8076, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.8076, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 381.43, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 361.35 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 401.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 361.35 } ], "minimum": 92.96708221, "maximum": 401.5 } ] }, { "description": "US RETROPERITONEAL COMP", "code_information": [ { "code": "76770", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 979, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 146.0668, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 146.0668, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 146.0668, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 146.0668, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 465.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 440.55 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 489.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 440.55 } ], "minimum": 92.96708221, "maximum": 489.5 } ] }, { "description": "US RETROPERITONEAL LTD", "code_information": [ { "code": "76775", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 803, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.8076, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.8076, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.8076, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.8076, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 381.43, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 361.35 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 401.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 361.35 } ], "minimum": 92.96708221, "maximum": 401.5 } ] }, { "description": "US TRANSVAGINAL", "code_information": [ { "code": "76830", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 777, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 115.9284, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 115.9284, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 115.9284, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 115.9284, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 369.08, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 349.65 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 388.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 349.65 } ], "minimum": 92.96708221, "maximum": 388.5 } ] }, { "description": "US PELVIS NON OB COMP", "code_information": [ { "code": "76856", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 890, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 132.788, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 132.788, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 132.788, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 132.788, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 422.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 400.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 445 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 400.5 } ], "minimum": 92.96708221, "maximum": 445 } ] }, { "description": "US PELVIS NON OB LTD", "code_information": [ { "code": "76857", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 890, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 132.788, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 132.788, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 132.788, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 132.788, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 422.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 400.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 445 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 400.5 } ], "minimum": 92.96708221, "maximum": 445 } ] }, { "description": "US SCROTUM", "code_information": [ { "code": "76870", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 723, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 107.8716, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 107.8716, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 107.8716, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 107.8716, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 343.43, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 325.35 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 361.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 325.35 } ], "minimum": 92.96708221, "maximum": 361.5 } ] }, { "description": "Us exam scrotum", "code_information": [ { "code": "76870", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 723, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 107.8716, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 107.8716, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 107.8716, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 107.8716, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 343.43, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 325.35 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 361.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 325.35 } ], "minimum": 92.96708221, "maximum": 361.5 } ] }, { "description": "US TRANSRECTAL", "code_information": [ { "code": "76872", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 451, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 67.2892, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 67.2892, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 67.2892, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 67.2892, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 214.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 202.95 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 225.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 202.95 } ], "minimum": 67.2892, "maximum": 259.74 } ] }, { "description": "Us transrectal", "code_information": [ { "code": "76872", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 451, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 67.2892, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 67.2892, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 67.2892, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 67.2892, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 214.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 202.95 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 225.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 202.95 } ], "minimum": 7, "maximum": 259.74 } ] }, { "description": "US EXTREMITY RT NON VASC LTD", "code_information": [ { "code": "76882", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 704, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 105.0368, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 105.0368, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.96708221, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 105.0368, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 105.0368, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 334.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5032, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 316.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 352 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 316.8 } ], "minimum": 92.96708221, "maximum": 352 } ] }, { "description": "Echo guide for biopsy", "code_information": [ { "code": "76942", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 198, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 29.5416, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 29.47 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 31.106856 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 29.5416, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 29.5416, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 29.5416, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 89.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 99 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 89.1 } ], "minimum": 29.47, "maximum": 99 } ] }, { "description": "Needle localization by xray", "code_information": [ { "code": "77002", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 435, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.902, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 86.87 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 91.681208 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.902, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.902, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.902, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 206.63, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 195.75 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 217.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 195.75 } ], "minimum": 64.902, "maximum": 217.5 } ] }, { "description": "ISTAT CHEM 8", "code_information": [ { "code": "80047", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 52, "discounted_cash": 27.46, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.1625, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.73, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 13.33 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 14.067758 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.73, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.5355, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.73, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.6133, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.46, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 37.76, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.73, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.968, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 12.357, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.73, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 11.74 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 23.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 26 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.4 } ], "minimum": 11.74, "maximum": 37.76 } ] }, { "description": "BASIC METABOLIC PANEL 8", "code_information": [ { "code": "80048", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 270.4, "discounted_cash": 16.92, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.575, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 8.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 8.668116 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.421, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.2366, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.29, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 128.44, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 23.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.536, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7.614, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 121.68 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 135.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 121.68 } ], "minimum": 7.24, "maximum": 135.2 } ] }, { "description": "BASIC METABOLIC PANEL DAILY", "code_information": [ { "code": "80048", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 270.4, "discounted_cash": 16.92, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.575, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 8.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 8.668116 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.421, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.2366, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.29, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 128.44, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 23.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.536, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7.614, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.46, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 121.68 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 135.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 121.68 } ], "minimum": 7.24, "maximum": 135.2 } ] }, { "description": "COMPREHENSIVE METABOLIC PANEL DAILY", "code_information": [ { "code": "80053", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 273, "discounted_cash": 21.12, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.2, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.56, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 10.25 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 10.819776 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.56, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.56, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.256, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1.56, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.7776, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1.53, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.56, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.56, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 129.68, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4.29, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.56, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.896, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 9.504, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.56, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 9.03 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 122.85 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 136.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 122.85 } ], "minimum": 1.53, "maximum": 136.5 } ] }, { "description": "COMPREHENSIVE METABOLIC PANEL 14", "code_information": [ { "code": "80053", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 273, "discounted_cash": 21.12, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.2, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 56, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.56, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 10.25 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 10.819776 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.56, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.56, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.256, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.56, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.7776, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.35, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.56, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.56, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 129.68, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 29.04, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.56, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.896, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 9.504, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.56, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 9.03 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 122.85 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 136.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 122.85 } ], "minimum": 9.03, "maximum": 136.5 } ] }, { "description": "LIPID PANEL", "code_information": [ { "code": "80061", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 117, "discounted_cash": 26.78, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.7375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 13 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 13.719394 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.0765, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.06, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.2019, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.84, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 55.58, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 30.42, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.424, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 12.051, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 11.45 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 52.65 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 58.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 52.65 } ], "minimum": 10.84, "maximum": 58.5 } ] }, { "description": "RENAL FUNCTION PANEL", "code_information": [ { "code": "80069", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 84.5, "discounted_cash": 17.36, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.85, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.68, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.68, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 8.43 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 8.893528 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.68, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.68, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.718, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.68, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.5028, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.51, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.68, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.68, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 40.14, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 23.87, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.68, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.888, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7.812, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.68, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7.42 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 38.025 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 42.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 38.025 } ], "minimum": 7.42, "maximum": 42.25 } ] }, { "description": "HEPATITIS PANEL ACUTE", "code_information": [ { "code": "80074", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 364, "discounted_cash": 95.26, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 59.5375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 46.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 48.801698 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 64.3005, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 57.6323, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 46.68, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 172.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 130.98, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 76.208, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 42.867, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 40.74 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 163.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 182 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 163.8 } ], "minimum": 40.74, "maximum": 182 } ] }, { "description": "HEPATIC FUNCTION PANEL", "code_information": [ { "code": "80076", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 226.2, "discounted_cash": 16.34, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.2125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 7.93 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 8.370982 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.0295, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.8857, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.01, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 107.45, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 22.47, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.072, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7.353, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.17, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6.99 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 101.79 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 113.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 101.79 } ], "minimum": 6.99, "maximum": 113.1 } ] }, { "description": "VALPROIC ACID, SERUM", "code_information": [ { "code": "80164", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.1, "discounted_cash": 27.08, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.925, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 13.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 13.873084 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.279, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.3834, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.27, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 47.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 37.24, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.664, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 12.186, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 11.58 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 45.045 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 50.05 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 45.045 } ], "minimum": 11.58, "maximum": 50.05 } ] }, { "description": "PHENOBARBITAL TOTAL", "code_information": [ { "code": "80184", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 87.1, "discounted_cash": 30.6, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15.3, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.72, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 14.85 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 15.67638 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.72, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.655, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.513, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.99, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.72, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.72, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 41.37, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 42.08, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 24.48, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 13.77, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 13.09 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 39.195 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 43.55 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 39.195 } ], "minimum": 13.09, "maximum": 43.55 } ] }, { "description": "VANCOMYCIN TROUGH", "code_information": [ { "code": "80202", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 87.1, "discounted_cash": 27.08, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.925, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 13.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 13.873084 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.279, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.3834, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.27, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 41.37, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 37.24, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.664, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 12.186, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 11.58 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 39.195 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 43.55 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 39.195 } ], "minimum": 11.58, "maximum": 43.55 } ] }, { "description": "VANCOMYCIN RANDOM", "code_information": [ { "code": "80202", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 87.1, "discounted_cash": 27.08, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.925, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 13.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 13.873084 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.279, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.3834, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.27, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 41.37, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 37.24, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.664, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 12.186, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.54, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 11.58 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 39.195 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 43.55 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 39.195 } ], "minimum": 11.58, "maximum": 43.55 } ] }, { "description": "DEXAMETHASONE", "code_information": [ { "code": "80299", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 55.92, "discounted_cash": 37.28, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 23.3, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 17.62, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 18.86 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 19.098544 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 17.62, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 25.164, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.5544, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.2672, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 17.62, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 17.62, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.562, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 51.26, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 29.824, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 16.776, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.64, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 15.94 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 25.164 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 27.96 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.164 } ], "minimum": 15.94, "maximum": 51.26 } ] }, { "description": "URINALYSIS COMPLETE W/MICRO", "code_information": [ { "code": "81001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18.2, "discounted_cash": 6.34, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3.9625, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.17, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.17, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3.08 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3.247982 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.17, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.17, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4.2795, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.17, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3.8357, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.11, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.17, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.17, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 8.65, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8.72, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.17, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.072, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2.853, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.17, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2.71 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.19 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.19 } ], "minimum": 2.71, "maximum": 9.1 } ] }, { "description": "URINE DIPSTICK", "code_information": [ { "code": "81003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 26, "discounted_cash": 4.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2.8125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.25, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.25, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2.18 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2.30535 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.25, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.25, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3.0375, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.25, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2.7225, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.21, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.25, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.25, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 12.35, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6.19, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.25, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3.6, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2.025, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.25, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1.92 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 11.7 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 13 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.7 } ], "minimum": 1.92, "maximum": 13 } ] }, { "description": "URINALYSIS", "code_information": [ { "code": "81005", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.51, "discounted_cash": 4.34, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2.7125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.17, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.17, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2.11 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2.223382 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.17, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.17, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2.9295, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.17, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2.6257, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.13, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.17, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.17, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5.97, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.17, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3.472, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1.953, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.17, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1.86 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.9295 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.255 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.9295 } ], "minimum": 1.86, "maximum": 5.97 } ] }, { "description": "URINE PREGNANCY TEST", "code_information": [ { "code": "81025", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 150.8, "discounted_cash": 17.22, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.7625, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.61, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 8.36 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 8.821806 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.61, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.6235, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.61, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.4181, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.44, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 71.63, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 23.68, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.61, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.776, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7.749, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.61, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7.36 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 67.86 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 75.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 67.86 } ], "minimum": 7.36, "maximum": 75.4 } ] }, { "description": "FACTOR V LEIDEN MUTATION ANALYSIS", "code_information": [ { "code": "81241", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 220.11, "discounted_cash": 146.74, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 91.7125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 73.37, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 55.03, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 71.23 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 75.174902 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 73.37, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 55.03, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 99.0495, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 73.37, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 88.7777, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 71.9, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 55.03, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 55.03, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 104.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 201.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 73.37, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 117.392, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 66.033, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 73.37, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 62.76 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 99.0495 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 110.055 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 99.0495 } ], "minimum": 55.03, "maximum": 201.77 } ] }, { "description": "MTHFR-HOMOCYSTEINE GENE MUTAT", "code_information": [ { "code": "81291", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 196.02, "discounted_cash": 130.68, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 81.675, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 65.34, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 63.43 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 66.947364 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 65.34, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 88.209, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 65.34, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 79.0614, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 64.03, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 93.11, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 179.69, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 65.34, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 104.544, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 58.806, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 65.34, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 55.89 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 88.209 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 98.01 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 88.209 } ], "minimum": 55.89, "maximum": 179.69 } ] }, { "description": "HLA-B27 DISEASE ASSOCIATION", "code_information": [ { "code": "81374", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 118.66, "discounted_cash": 148.66, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 92.9125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 74.33, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 72.16 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 76.158518 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 74.33, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 100.3455, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 74.33, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 89.9393, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 72.84, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 56.36, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 204.41, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 74.33, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.928, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 66.897, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 74.33, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 63.58 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 53.397 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 59.33 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 53.397 } ], "minimum": 53.397, "maximum": 204.41 } ] }, { "description": "ALBUMIN SERUM", "code_information": [ { "code": "82040", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 36.4, "discounted_cash": 9.9, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.1875, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5.07177 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.6825, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.9895, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.85, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.29, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 13.61, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.92, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4.455, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.95, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4.23 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.38 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.38 } ], "minimum": 4.23, "maximum": 18.2 } ] }, { "description": "MICROALBUMIN, URINE RANDOM", "code_information": [ { "code": "82043", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.7, "discounted_cash": 11.56, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.225, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5.61 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5.922188 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.803, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.9938, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.66, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.91, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 15.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.248, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5.202, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4.94 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.965 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.85 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.965 } ], "minimum": 4.94, "maximum": 18.85 } ] }, { "description": "ALDOLASE", "code_information": [ { "code": "82085", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 93.6, "discounted_cash": 19.42, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.1375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 9.43 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 9.948866 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.1085, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.7491, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.52, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 44.46, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 26.7, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.536, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 8.739, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 8.31 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 42.12 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 46.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 42.12 } ], "minimum": 8.31, "maximum": 46.8 } ] }, { "description": "AMMONIA", "code_information": [ { "code": "82140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 105.3, "discounted_cash": 29.14, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.2125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 14.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 14.928422 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.6695, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.6297, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.28, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 50.02, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 40.07, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 23.312, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 13.113, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.57, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12.46 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 47.385 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 52.65 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 47.385 } ], "minimum": 12.46, "maximum": 52.65 } ] }, { "description": "AMYLASE SERUM", "code_information": [ { "code": "82150", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 46.8, "discounted_cash": 12.96, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.1, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.29 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.639408 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.748, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.8408, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.35, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 22.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17.82, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.368, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5.832, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5.54 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 21.06 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.06 } ], "minimum": 5.54, "maximum": 23.4 } ] }, { "description": "ANGIOTENSIN CONVERTING ENZYME,BLD OR CSF", "code_information": [ { "code": "82164", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 130, "discounted_cash": 29.2, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.25, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 14.17 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 14.95916 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.71, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.666, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.31, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 40.15, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 23.36, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 13.14, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.6, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12.49 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 58.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 65 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 58.5 } ], "minimum": 12.49, "maximum": 65 } ] }, { "description": "APOLIPOPROTEIN B", "code_information": [ { "code": "82172", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 109.77, "discounted_cash": 42.18, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 26.3625, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 20.47 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 21.608814 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 28.4715, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 25.5189, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 20.67, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.14, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 58, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 33.744, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 18.981, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.09, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 18.04 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 49.3965 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 54.885 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 49.3965 } ], "minimum": 18.04, "maximum": 58 } ] }, { "description": "BILIRUBIN DIRECT", "code_information": [ { "code": "82248", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 24.7, "discounted_cash": 10.04, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.275, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.84, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4.87 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5.143492 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.84, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.777, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.0742, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.92, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.84, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.84, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.73, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 13.81, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.032, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4.518, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4.29 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 11.115 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.35 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.115 } ], "minimum": 4.29, "maximum": 13.81 } ] }, { "description": "OCCULT BLOOD SCREEN(1-3)", "code_information": [ { "code": "82270", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 112.84, "discounted_cash": 8.76, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.475, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.38, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.23, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4.25 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4.487748 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.38, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.23, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.913, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.38, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.2998, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.29, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.23, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.23, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 53.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.38, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.008, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3.942, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.38, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3.75 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 50.778 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 56.42 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 50.778 } ], "minimum": 3.23, "maximum": 56.42 } ] }, { "description": "VIT D 25-HYDROXY", "code_information": [ { "code": "82306", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 356.2, "discounted_cash": 59.2, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 37, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 28.74 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 30.32816 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 39.96, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 35.816, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 29.01, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 169.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 81.4, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 47.36, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 26.64, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 25.32 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 160.29 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 178.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 160.29 } ], "minimum": 25.32, "maximum": 178.1 } ] }, { "description": "CALCIUM SERUM", "code_information": [ { "code": "82310", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.7, "discounted_cash": 10.32, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.45, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5.286936 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.966, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.2436, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.91, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14.19, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.256, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4.644, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.16, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.965 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.85 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.965 } ], "minimum": 4.41, "maximum": 18.85 } ] }, { "description": "IONIZED CALCIUM ISTAT", "code_information": [ { "code": "82330", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.1, "discounted_cash": 27.36, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.1, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 13.84 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 14.016528 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.468, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.5528, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.41, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 47.5475, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 37.62, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.68, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.888, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 12.312, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.68 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 11.7 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 45.045 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 50.05 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 45.045 } ], "minimum": 11.7, "maximum": 50.05 } ] }, { "description": "STONE ANALYSIS", "code_information": [ { "code": "82365", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 92.14, "discounted_cash": 25.8, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 12.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 13.21734 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.415, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.609, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.64, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 43.77, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 35.48, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.64, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 11.61, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 11.03 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 41.463 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 46.07 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 41.463 } ], "minimum": 11.03, "maximum": 46.07 } ] }, { "description": "CEA", "code_information": [ { "code": "82378", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 137.8, "discounted_cash": 37.92, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 23.7, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 18.41 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 19.426416 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 25.596, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.9416, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.58, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 65.46, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 52.14, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 30.336, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 17.064, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 16.22 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 62.01 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 68.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 62.01 } ], "minimum": 16.22, "maximum": 68.9 } ] }, { "description": "CHROMIUM LEVEL", "code_information": [ { "code": "82495", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 61, "discounted_cash": 40.56, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 25.35, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 19.69 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 20.778888 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 27.378, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 24.5388, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 19.87, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 28.98, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 55.77, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 32.448, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 18.252, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 20.28, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 17.35 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 27.45 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 30.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 27.45 } ], "minimum": 17.35, "maximum": 55.77 } ] }, { "description": "COPPER SERUM", "code_information": [ { "code": "82525", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 89.7, "discounted_cash": 24.82, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.5125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 12.05 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12.715286 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.7535, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.0161, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.16, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.61, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 34.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.856, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 11.169, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.41, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 10.62 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 40.365 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 44.85 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 40.365 } ], "minimum": 10.62, "maximum": 44.85 } ] }, { "description": "PROTEIN ELECTROPHORESIS, URINE, RANDOM", "code_information": [ { "code": "82530", "type": "HCPCS" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 135.2, "discounted_cash": 33.42, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.8875, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.71, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.71, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 16.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 17.121066 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.71, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.71, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.5585 }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.71, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.2191, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.38, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.71, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.71, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 64.22, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 46.75, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.71, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 26.736, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 15.039, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.71 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 14.29 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 60.84 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 67.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 60.84 } ], "minimum": 14.29, "maximum": 67.6 } ] }, { "description": "CORTISOL", "code_information": [ { "code": "82533", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 118.3, "discounted_cash": 32.6, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.3, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.3, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 16.49 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 16.70098 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.3, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.005 }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.723, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15.97, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.3, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.3, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 56.1925, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 26.08, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14.67, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.3 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 13.94 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 53.235 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 59.15 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 53.235 } ], "minimum": 13.94, "maximum": 59.15 } ] }, { "description": "LAMOTRIGINE, SERUM (LAMICTAL)", "code_information": [ { "code": "82542", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 149.5, "discounted_cash": 48.18, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 30.1125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 23.39 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 24.682614 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 32.5215, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 29.1489, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 23.61, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 71.01, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 66.25, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 38.544, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 21.681, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24.09, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 20.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 67.275 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 74.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 67.275 } ], "minimum": 20.61, "maximum": 74.75 } ] }, { "description": "CPK TOTAL", "code_information": [ { "code": "82550", "type": "HCPCS" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 46.8, "discounted_cash": 13.02, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.1375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.32 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.670146 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.7885, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.8771, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.38, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 22.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.416, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5.859, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.51, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5.57 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 21.06 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.06 } ], "minimum": 5.57, "maximum": 23.4 } ] }, { "description": "CK w ISOENZYMES", "code_information": [ { "code": "82552", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 84.5, "discounted_cash": 26.78, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.7375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 13 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 13.719394 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.0765, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.2019, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.12, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 40.14, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 36.82, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.424, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 12.051, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 11.45 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 38.025 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 42.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 38.025 } ], "minimum": 11.45, "maximum": 42.25 } ] }, { "description": "CREATININE I STAT", "code_information": [ { "code": "82565", "type": "HCPCS" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.7, "discounted_cash": 10.24, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.4, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4.97 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5.245952 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.912, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.1952, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.91, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14.08, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.192, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4.608, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4.38 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.965 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.85 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.965 } ], "minimum": 4.38, "maximum": 18.85 } ] }, { "description": "CREATININE SERUM", "code_information": [ { "code": "82565", "type": "HCPCS" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.7, "discounted_cash": 10.24, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.4, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4.97 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5.245952 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.912, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.1952, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.02, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.91, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14.08, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.192, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4.608, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.12, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4.38 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.965 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.85 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.965 } ], "minimum": 4.38, "maximum": 18.85 } ] }, { "description": "CREATININE URINE", "code_information": [ { "code": "82570", "type": "HCPCS" }, { "code": "307", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.7, "discounted_cash": 10.36, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.475, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5.03 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5.307428 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.993, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.2678, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.08, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.91, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14.25, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.288, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4.662, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4.43 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.965 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.85 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.965 } ], "minimum": 4.43, "maximum": 18.85 } ] }, { "description": "VITAMIN B 12", "code_information": [ { "code": "82607", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 143, "discounted_cash": 30.16, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.85, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 14.64 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 15.450968 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.358, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.2468, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.78, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 67.93, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 41.47, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 24.128, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 13.572, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12.9 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 64.35 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 71.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 64.35 } ], "minimum": 12.9, "maximum": 71.5 } ] }, { "description": "VIT D 1,25 DIHYDROXY", "code_information": [ { "code": "82652", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 510.9, "discounted_cash": 77, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 48.125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 38.5, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 37.38 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 39.4471 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 38.5, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 51.975, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 38.5, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 46.585, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 37.73, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 20.52, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 242.68, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 105.88, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 38.5, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 61.6, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 34.65, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 38.5, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 32.93 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 229.905 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 255.45 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 229.905 } ], "minimum": 20.52, "maximum": 255.45 } ] }, { "description": "ESTRADIOL", "code_information": [ { "code": "82670", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 96.2, "discounted_cash": 55.88, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 34.925, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 27.94, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 27.94, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 27.12 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 28.627324 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 27.94, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 27.94, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 37.719, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 27.94, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 33.8074, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 27.38, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 27.94, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 27.94, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 45.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 76.84, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 27.94, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 44.704, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 25.146, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 27.94, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 23.9 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 43.29 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 48.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 43.29 } ], "minimum": 23.9, "maximum": 76.84 } ] }, { "description": "ESTROGENS, TOTAL", "code_information": [ { "code": "82672", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 166.4, "discounted_cash": 43.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 27.125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 21.07 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 22.23382 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 29.295, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 26.257, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.27, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 79.04, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 59.68, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 34.72, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 19.53, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.7, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 18.56 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 74.88 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 83.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 74.88 } ], "minimum": 18.56, "maximum": 83.2 } ] }, { "description": "FERRITIN", "code_information": [ { "code": "82728", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 98.8, "discounted_cash": 27.26, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.0375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 13.23 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 13.965298 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.4005, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.4923, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.36, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 46.93, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 37.48, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.808, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 12.267, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 11.66 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 44.46 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 49.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 44.46 } ], "minimum": 11.66, "maximum": 49.4 } ] }, { "description": "FOLIC ACID, SERUM", "code_information": [ { "code": "82746", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 106.6, "discounted_cash": 29.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 14.27 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 15.06162 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.845, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.787, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.41, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 50.64, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 40.43, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 23.52, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 13.23, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.7, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12.57 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 47.97 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 53.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 47.97 } ], "minimum": 12.57, "maximum": 53.3 } ] }, { "description": "QUANT IGG, ELECTROPHORESIS", "code_information": [ { "code": "82784", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 88.4, "discounted_cash": 18.6, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.625, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 9.03 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 9.52878 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.555, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.253, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.11, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 41.99, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 25.58, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.88, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 8.37, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7.96 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 39.78 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 44.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 39.78 } ], "minimum": 7.96, "maximum": 44.2 } ] }, { "description": "IMMUNOGLOBULIN G", "code_information": [ { "code": "82784", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 370.5, "discounted_cash": 18.6, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.625, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 9.03 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 9.52878 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.555, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.253, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.11, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 175.99, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 25.58, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.88, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 8.37, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7.96 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 166.725 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 185.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 166.725 } ], "minimum": 7.96, "maximum": 185.25 } ] }, { "description": "IMMUNOGLOBULINS, QUANT A,E,G,M", "code_information": [ { "code": "82784", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 27.9, "discounted_cash": 18.6, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.625, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 9.03 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 9.52878 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.555, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.253, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.11, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.25, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 25.58, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.88, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 8.37, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7.96 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 12.555 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.95 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.555 } ], "minimum": 7.96, "maximum": 25.58 } ] }, { "description": "IMMUNOGLOBULIN E TOTAL", "code_information": [ { "code": "82785", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 130, "discounted_cash": 32.92, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.575, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 15.98 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 16.864916 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.221, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.9166, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.13, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 45.27, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 26.336, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14.814, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 14.08 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 58.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 65 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 58.5 } ], "minimum": 14.08, "maximum": 65 } ] }, { "description": "IGG SUBCLASS", "code_information": [ { "code": "82787", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 39, "discounted_cash": 16.04, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.025, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.02, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.75, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 8.11 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 8.217292 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.02, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.75, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.827 }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.02, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.7042, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.86, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.75, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.75, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 18.525, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 22.055, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.02, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.832, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7.218, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.02 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6.86 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 17.55 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.55 } ], "minimum": 6.75, "maximum": 22.055 } ] }, { "description": "BLOOD GAS-ISTAT", "code_information": [ { "code": "82803", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 39, "discounted_cash": 52.14, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 32.5875, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.35, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 25.31 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 26.711322 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.35, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 35.1945, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 31.5447, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 25.55, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.35, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.35, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 18.53, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 71.69, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 41.712, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 23.463, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 26.07, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 22.3 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 17.55 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.55 } ], "minimum": 6.35, "maximum": 71.69 } ] }, { "description": "GLUCOSE SERUM", "code_information": [ { "code": "82947", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 28.6, "discounted_cash": 7.86, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4.9125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4.026678 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.3055, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4.7553, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.85, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.288, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3.537, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3.36 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 12.87 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.87 } ], "minimum": 3.36, "maximum": 14.3 } ] }, { "description": "GAMMA GLUTAMYL TRANSPEPT GGT", "code_information": [ { "code": "82977", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 52, "discounted_cash": 14.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.2, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.2, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.99 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 7.37712 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.2, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.2, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.72, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.2, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.712, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.06, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.2, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.2, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 19.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.2, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.52, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6.48, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.2, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6.16 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 23.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 26 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.4 } ], "minimum": 6.16, "maximum": 26 } ] }, { "description": "FSH", "code_information": [ { "code": "83001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 109, "discounted_cash": 37.16, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 23.225, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.58, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 18.58, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 18.8 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 19.037068 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.58, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 18.58, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 25.083 }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.58, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.4818, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.2084, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 18.58, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 18.58, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 51.775, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 51.095, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.58, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 29.728, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 16.722, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.58 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 15.89 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 49.05 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 54.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 49.05 } ], "minimum": 15.89, "maximum": 54.5 } ] }, { "description": "LUTEINIZING HORMONE", "code_information": [ { "code": "83002", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 135.2, "discounted_cash": 37.04, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 23.15, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.52, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 18.52, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 17.98 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 18.975592 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.52, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 18.52, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 25.002, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.52, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.4092, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.15, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 18.52, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 18.52, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 64.22, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 50.93, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.52, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 29.632, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 16.668, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.52, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 15.84 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 60.84 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 67.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 60.84 } ], "minimum": 15.84, "maximum": 67.6 } ] }, { "description": "COBALT", "code_information": [ { "code": "83018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 66, "discounted_cash": 43.92, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 27.45, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 21.32 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 22.500216 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 29.646, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 26.5716, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.52, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 31.35, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 60.39, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 35.136, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 19.764, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.96, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 18.78 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 29.7 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 33 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.7 } ], "minimum": 10.36, "maximum": 60.39 } ] }, { "description": "HEMOGLOBIN A1C", "code_information": [ { "code": "83036", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 70.2, "discounted_cash": 19.42, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.1375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 9.43 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 9.948866 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.1085, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.7491, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.52, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 33.35, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 26.7, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.536, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 8.739, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.71, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 8.31 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 31.59 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 35.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 31.59 } ], "minimum": 8.31, "maximum": 35.1 } ] }, { "description": "HOMOCYSTEINE", "code_information": [ { "code": "83090", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 130, "discounted_cash": 35.84, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.4, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 17.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 18.360832 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 24.192, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.6832, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.56, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 49.28, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 28.672, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 16.128, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.92, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 15.33 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 58.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 65 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 58.5 } ], "minimum": 15.33, "maximum": 65 } ] }, { "description": "ACETYLCHOLINE RECEPTOR BINDING AB, SERUM", "code_information": [ { "code": "83519", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.7, "discounted_cash": 36.8, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 23, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.68, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 17.86 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 18.85264 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.68, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 24.84, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.264, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.03, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.68, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.68, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.91, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 50.6, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 29.44, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 16.56, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.4, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 15.74 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.965 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.85 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.965 } ], "minimum": 5.68, "maximum": 50.6 } ] }, { "description": "INSULIN SERUM", "code_information": [ { "code": "83525", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 83.2, "discounted_cash": 22.86, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.2875, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11.56 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 11.711178 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.4305 }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.8303, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.2014, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 39.52, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 30.25, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.43, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.288, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 10.287, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.43 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 9.78 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 37.44 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 41.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 37.44 } ], "minimum": 9.78, "maximum": 41.6 } ] }, { "description": "MERCURY, PLASMA", "code_information": [ { "code": "83528", "type": "HCPCS" }, { "code": "300", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 135.62, "discounted_cash": 39.64, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 24.775, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 19.82, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 15.2, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 20.05 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 20.307572 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 19.82, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 15.2, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 26.757 }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 19.82, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 23.9822, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 19.4236, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 15.2, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 15.2, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 64.4195, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 55, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 19.82, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 31.712, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 17.838, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 19.82 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 16.95 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 61.029 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 67.81 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 61.029 } ], "minimum": 15.2, "maximum": 67.81 } ] }, { "description": "IRON AND TIBC", "code_information": [ { "code": "83550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 63.7, "discounted_cash": 17.48, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.925, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.74, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 8.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 8.955004 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.74, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.799, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.74, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.5754, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.57, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 30.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 24.04, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.74, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.984, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7.866, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.74, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7.48 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 28.665 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 31.85 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 28.665 } ], "minimum": 7.48, "maximum": 31.85 } ] }, { "description": "LDH", "code_information": [ { "code": "83615", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 44.2, "discounted_cash": 12.08, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.55, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.04, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.04, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5.86 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.188584 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.04, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.04, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.154, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.04, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.3084, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.92, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.04, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.04, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 21, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 16.61, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.04, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.664, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5.436, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.04, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5.17 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 19.89 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.89 } ], "minimum": 5.17, "maximum": 22.1 } ] }, { "description": "LIPASE", "code_information": [ { "code": "83690", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 49.4, "discounted_cash": 13.78, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.6125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.69 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 7.059494 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.3015, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.3369, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.75, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 23.47, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 18.95, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.024, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6.201, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.89, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5.89 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 22.23 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 24.7 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.23 } ], "minimum": 5.89, "maximum": 24.7 } ] }, { "description": "LIPOPROTEIN A", "code_information": [ { "code": "83695", "type": "HCPCS" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 42.96, "discounted_cash": 28.64, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.9, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 14.49 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 14.672272 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.332 }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.3272, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.0336, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 20.406, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 39.38, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.32, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.912, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 12.888, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.32 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12.25 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 19.332 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.48 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.332 } ], "minimum": 12.25, "maximum": 39.38 } ] }, { "description": "MAGNESIUM SERUM", "code_information": [ { "code": "83735", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 48.1, "discounted_cash": 13.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.5 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.86482 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.045, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.107, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.57, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 22.85, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 18.43, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.72, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 21.645 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 24.05 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.645 } ], "minimum": 5.73, "maximum": 24.05 } ] }, { "description": "MAGNESIUM SERUM DAILY", "code_information": [ { "code": "83735", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 48.1, "discounted_cash": 13.4, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.5 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.86482 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.045, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.107, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.57, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 22.85, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 18.43, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.72, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6.03, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.7, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 21.645 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 24.05 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.645 } ], "minimum": 5.73, "maximum": 24.05 } ] }, { "description": "BNP B TYPE NATURETIC PEPTIDE", "code_information": [ { "code": "83880", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 247, "discounted_cash": 78.52, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 49.075, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 38.11 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 40.225796 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 53.001, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 47.5046, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 38.47, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 117.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 107.97, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 62.816, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 35.334, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 39.26, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 33.58 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 111.15 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 123.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 111.15 } ], "minimum": 33.58, "maximum": 123.5 } ] }, { "description": "METHYLMALONIC ACID, SERUM", "code_information": [ { "code": "83921", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 115.7, "discounted_cash": 42.42, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 26.5125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 20.59 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 21.731766 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 28.6335, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 25.6641, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 20.79, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 54.96, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 58.33, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 33.936, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 19.089, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 18.14 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 52.065 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 57.85 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 52.065 } ], "minimum": 18.14, "maximum": 58.33 } ] }, { "description": "OSMOLALITY SERUM", "code_information": [ { "code": "83930", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 48.1, "discounted_cash": 13.22, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.2625, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.69 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.772606 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.9235 }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.9981, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.4778, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 22.8475, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 18.1775, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.61, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.576, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5.949, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.61 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5.65 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 21.645 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 24.05 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.645 } ], "minimum": 5.65, "maximum": 24.05 } ] }, { "description": "OSMOLALITY URINE", "code_information": [ { "code": "83935", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 49.4, "discounted_cash": 13.64, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.525, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.82, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.82, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.62 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.987772 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.82, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.82, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.207, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.2522, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.82, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.82, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 23.47, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 18.76, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.82, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.912, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6.138, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.82, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5.83 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 22.23 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 24.7 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.23 } ], "minimum": 5.83, "maximum": 24.7 } ] }, { "description": "PTHI", "code_information": [ { "code": "83970", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 209.3, "discounted_cash": 82.56, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 51.6, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 41.28, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 41.28, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 40.07 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 42.295488 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 41.28, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 41.28, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 55.728, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 49.9488, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 40.45, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 41.28, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 41.28, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 99.42, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 113.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 41.28, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 66.048, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 37.152, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 41.28, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 35.31 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 94.185 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 104.65 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 94.185 } ], "minimum": 21.21, "maximum": 113.52 } ] }, { "description": "PHOSPHORUS SERUM", "code_information": [ { "code": "84100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35.1, "discounted_cash": 9.48, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.925, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.74, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4.6 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4.856604 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.74, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.399, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.7354, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.65, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.67, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 13.04, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.74, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.584, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4.266, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.74, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.795 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.55 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.795 } ], "minimum": 4.05, "maximum": 21.21 } ] }, { "description": "ISTAT POTASSIUM", "code_information": [ { "code": "84132", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 33.8, "discounted_cash": 9.52, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4.62 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4.877096 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.426, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.7596, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.66, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.06, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 13.09, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.616, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4.284, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.21 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.21 } ], "minimum": 4.07, "maximum": 21.21 } ] }, { "description": "POTASSIUM", "code_information": [ { "code": "84132", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 33.8, "discounted_cash": 9.52, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.95, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4.62 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4.877096 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.426, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.7596, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.66, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.06, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 13.09, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.616, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4.284, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.76, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4.07 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.21 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.21 } ], "minimum": 4.07, "maximum": 21.21 } ] }, { "description": "PREALBUMIN", "code_information": [ { "code": "84134", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 40.3, "discounted_cash": 29.18, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.2375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.59, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 14.16 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 14.948914 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.59, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.6965, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.6539, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.3, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 19.14, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 40.12, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.59, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 23.344, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 13.131, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.59, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12.48 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 18.135 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.15 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.135 } ], "minimum": 6.81, "maximum": 40.12 } ] }, { "description": "PROGESTERONE", "code_information": [ { "code": "84143", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 166.4, "discounted_cash": 45.62, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 28.5125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 22.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 23.371126 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 30.7935, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 27.6001, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 22.35, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 79.04, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 62.73, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 36.496, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 20.529, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 22.81, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 19.51 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 74.88 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 83.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 74.88 } ], "minimum": 19.51, "maximum": 83.2 } ] }, { "description": "PSA DIAGNOSTIC", "code_information": [ { "code": "84153", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 133.9, "discounted_cash": 36.78, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.9875, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 17.85 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 18.842394 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 24.8265, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.2519, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.02, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 63.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 50.57, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 29.424, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 16.551, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 15.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 60.255 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 66.95 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 60.255 } ], "minimum": 15.73, "maximum": 66.95 } ] }, { "description": "PSA SCREENING", "code_information": [ { "code": "84153", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 133.9, "discounted_cash": 36.78, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.9875, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 17.85 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 18.842394 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 24.8265, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.2519, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.02, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 63.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 50.57, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 29.424, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 16.551, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 18.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 15.73 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 60.255 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 66.95 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 60.255 } ], "minimum": 15.73, "maximum": 66.95 } ] }, { "description": "PROTEIN TOTAL-SERUM", "code_information": [ { "code": "84155", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 26, "discounted_cash": 7.34, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4.5875, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3.56 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3.760282 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4.9545, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4.4407, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.6, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 12.35, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 10.09, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.872, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3.303, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3.14 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 11.7 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 13 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.7 } ], "minimum": 3.14, "maximum": 21.21 } ] }, { "description": "PROTEIN URINE", "code_information": [ { "code": "84156", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 26, "discounted_cash": 7.34, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4.5875, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3.56 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3.760282 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4.9545, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4.4407, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.6, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 12.35, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 10.09, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.872, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3.303, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3.14 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 11.7 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 13 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.7 } ], "minimum": 3.14, "maximum": 21.21 } ] }, { "description": "SERUM PROTEIN ELETROPHORESIS", "code_information": [ { "code": "84165", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.1, "discounted_cash": 21.48, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.425, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 10.43 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 11.004204 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.499, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.9954, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.53, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 47.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 29.54, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.184, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 9.666, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 9.19 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 45.045 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 50.05 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 45.045 } ], "minimum": 9.19, "maximum": 50.05 } ] }, { "description": "VIT B6 PLASMA", "code_information": [ { "code": "84207", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 130, "discounted_cash": 56.2, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 35.125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 28.1, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 17.22, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 27.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 28.79126 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 28.1, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 17.22, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 37.935, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 34.001, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 27.54, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 17.22, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 17.22, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 77.28, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 28.1, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 44.96, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 25.29, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 28.1, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 24.04 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 58.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 65 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 58.5 } ], "minimum": 17.22, "maximum": 77.28 } ] }, { "description": "SOLUBLE TRANSFERRIN RECEPTOR", "code_information": [ { "code": "84238", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 109.71, "discounted_cash": 73.14, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 45.7125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 35.5 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 37.469622 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 49.3695, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 44.2497, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 35.84, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.11, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 100.57, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 58.512, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 32.913, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 36.57, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 31.28 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 49.3695 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 54.855 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 49.3695 } ], "minimum": 21.21, "maximum": 100.57 } ] }, { "description": "SEX HORMONE BINDING GLOBULIN", "code_information": [ { "code": "84270", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 155.32, "discounted_cash": 43.46, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 27.1625, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.73, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.24, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 21.1 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 22.264558 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.73, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.24, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 29.3355, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 26.2933, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.3, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.24, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.24, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 73.78, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 59.76, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.73, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 34.768, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 19.557, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.73, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 18.59 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 69.894 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 77.66 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 69.894 } ], "minimum": 6.24, "maximum": 77.66 } ] }, { "description": "SODIUM", "code_information": [ { "code": "84295", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35.1, "discounted_cash": 9.62, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.0125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4.67 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4.928326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.4935, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.8201, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.71, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.67, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 13.23, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.696, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4.329, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4.11 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.795 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.55 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.795 } ], "minimum": 4.11, "maximum": 21.21 } ] }, { "description": "ISTAT SODIUM", "code_information": [ { "code": "84295", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35.1, "discounted_cash": 9.62, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.0125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4.67 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4.928326 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.4935, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.8201, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.71, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.67, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 13.23, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.696, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4.329, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.81, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4.11 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.795 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.55 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.795 } ], "minimum": 4.11, "maximum": 21.21 } ] }, { "description": "SODIUM 24HR UA", "code_information": [ { "code": "84300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35.1, "discounted_cash": 10.12, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.325, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4.91 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5.184476 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.831, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.1226, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.96, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.67, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 13.92, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.096, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4.554, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4.33 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.795 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.55 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.795 } ], "minimum": 4.33, "maximum": 21.21 } ] }, { "description": "SODIUM, URINE RANDOM", "code_information": [ { "code": "84300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 35.1, "discounted_cash": 10.12, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.325, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4.91 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5.184476 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.831, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.1226, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.96, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.67, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 13.92, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.096, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4.554, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.06, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4.33 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.795 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.55 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.795 } ], "minimum": 4.33, "maximum": 21.21 } ] }, { "description": "TESTOSTERONE, FREE DIRECT", "code_information": [ { "code": "84402", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.7, "discounted_cash": 50.94, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 31.8375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 25.47, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 25.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 24.73 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 26.096562 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 25.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 25.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 34.3845, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 30.8187, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24.96, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 25.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 25.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.91, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 70.04, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 25.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 40.752, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 22.923, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 25.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 21.79 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.965 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.85 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.965 } ], "minimum": 16.965, "maximum": 70.04 } ] }, { "description": "TESTOSTERONE, TOTAL, SERUM", "code_information": [ { "code": "84403", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 208, "discounted_cash": 51.62, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 32.2625, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 25.81, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 25.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 25.06 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 26.444926 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 25.81, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 25.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 34.8435, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.21, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 31.2301, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 25.29, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 25.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 25.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 98.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 70.98, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 25.81, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 41.296, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 23.229, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 25.81, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 22.08 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 93.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 104 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 93.6 } ], "minimum": 21.21, "maximum": 104 } ] }, { "description": "VITAMIN B1, WHOLE BLOOD", "code_information": [ { "code": "84425", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 183.3, "discounted_cash": 42.46, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 26.5375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.23, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 21.23, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 20.61 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 21.752258 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.23, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 21.23, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 28.6605, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.23, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 25.6883, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 20.81, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 21.23, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 21.23, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 87.07, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 58.38, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.23, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 33.968, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 19.107, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.23, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 18.16 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 82.485 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 91.65 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 82.485 } ], "minimum": 18.16, "maximum": 91.65 } ] }, { "description": "THYROXINE, TOTAL", "code_information": [ { "code": "84436", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 46.8, "discounted_cash": 13.74, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.5875, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.87, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.86, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.67 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 7.039002 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.87, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.86, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.2745, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.87, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.3127, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.73, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.86, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.86, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 22.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 18.89, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.87, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.992, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6.183, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.87, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5.88 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 21.06 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.06 } ], "minimum": 5.86, "maximum": 23.4 } ] }, { "description": "T4 FREE", "code_information": [ { "code": "84439", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 228.8, "discounted_cash": 18.04, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.275, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.02, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.02, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 8.76 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 9.241892 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.02, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.02, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.177, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.02, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.9142, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.84, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.02, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.02, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 108.68, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 24.81, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.02, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.432, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 8.118, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.02, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 102.96 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 114.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 102.96 } ], "minimum": 7.72, "maximum": 114.4 } ] }, { "description": "TSH", "code_information": [ { "code": "84443", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 130, "discounted_cash": 33.6, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.8, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.8, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 16.31 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 17.21328 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.8, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.8, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.68, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.8, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.328, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.8, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.8, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 46.2, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.8, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 26.88, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 15.12, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.8, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 14.37 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 58.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 65 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 58.5 } ], "minimum": 14.37, "maximum": 65 } ] }, { "description": "VITAMIN E", "code_information": [ { "code": "84446", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 130, "discounted_cash": 28.36, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.725, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 13.77 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 14.528828 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.143, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.1578, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.9, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 39, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.688, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 12.762, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 58.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 65 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 58.5 } ], "minimum": 12.13, "maximum": 65 } ] }, { "description": "TRANSFERRIN", "code_information": [ { "code": "84466", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 115.7, "discounted_cash": 25.52, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.95, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.76, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.76, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 12.39 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 13.073896 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.76, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.76, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.226, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.76, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.4396, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.5, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.76, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.76, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 54.96, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 35.09, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.76, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.416, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 11.484, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.76, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 10.91 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 52.065 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 57.85 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 52.065 } ], "minimum": 10.91, "maximum": 57.85 } ] }, { "description": "TRIGLYCERIDES", "code_information": [ { "code": "84478", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 41.6, "discounted_cash": 11.48, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.175, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.74, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5.57 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5.881204 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.74, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.749, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.74, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.9454, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.63, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 19.76, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 15.79, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.74, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.184, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5.166, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.74, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4.91 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 18.72 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.72 } ], "minimum": 4.91, "maximum": 20.8 } ] }, { "description": "T3 UPTAKE", "code_information": [ { "code": "84479", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 33.8, "discounted_cash": 12.94, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.0875, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.69, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.629162 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.69, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.7345, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.8287, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.34, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.69, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.69, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.06, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17.79, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.352, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5.823, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5.53 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.21 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.21 } ], "minimum": 5.53, "maximum": 17.79 } ] }, { "description": "T3 TOTAL", "code_information": [ { "code": "84480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 46.8, "discounted_cash": 28.36, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.725, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.83, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 13.77 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 14.528828 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.83, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.143, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.1578, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.9, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.83, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.83, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 22.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 39, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.688, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 12.762, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12.13 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 21.06 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.06 } ], "minimum": 7.83, "maximum": 39 } ] }, { "description": "T3 FREE", "code_information": [ { "code": "84481", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 114.4, "discounted_cash": 33.88, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.175, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 16.45 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 17.356724 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.869, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.4974, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.6, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 54.34, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 46.59, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 27.104, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 15.246, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.94, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 14.49 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 51.48 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 57.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 51.48 } ], "minimum": 12.02, "maximum": 57.2 } ] }, { "description": "TROPONIN", "code_information": [ { "code": "84484", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 299, "discounted_cash": 24.94, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.5875, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.47, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 12.11 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12.776762 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.8345, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.0887, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.22, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 34.29, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.952, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 11.223, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 10.67 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 134.55 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 149.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 134.55 } ], "minimum": 10.67, "maximum": 149.5 } ] }, { "description": "BUN I STAT", "code_information": [ { "code": "84520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.7, "discounted_cash": 7.9, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4.9375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3.83 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4.04717 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.3325, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4.7795, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.87, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.91, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 10.86, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.32, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3.555, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3.38 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.965 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.85 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.965 } ], "minimum": 3.38, "maximum": 18.85 } ] }, { "description": "BLOOD UREA NITROGEN SERUM (BUN)", "code_information": [ { "code": "84520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 28.6, "discounted_cash": 7.9, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4.9375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3.83 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4.04717 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.3325, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4.7795, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.87, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 10.86, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.32, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3.555, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.95, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3.38 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 12.87 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.87 } ], "minimum": 3.38, "maximum": 14.3 } ] }, { "description": "URIC ACID SERUM", "code_information": [ { "code": "84550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 97.5, "discounted_cash": 9.04, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.65, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.52, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.52, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4.39 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4.631192 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.52, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.52, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.102, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.52, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.4692, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.43, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.52, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.52, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 46.31, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 12.43, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.52, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.232, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4.068, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.52, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3.87 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 43.875 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 48.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 43.875 } ], "minimum": 3.87, "maximum": 48.75 } ] }, { "description": "SERUM PREGNANCY TEST", "code_information": [ { "code": "84703", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 57.2, "discounted_cash": 15.04, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.4, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.52, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.52, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 7.3 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 7.704992 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.52, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.52, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.152, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.52, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.0992, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.37, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.52, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.52, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 27.17, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 20.68, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.52, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.032, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6.768, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.52, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6.43 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 25.74 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 28.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.74 } ], "minimum": 6.43, "maximum": 28.6 } ] }, { "description": "CBC DIFFERENTIAL MANUAL", "code_information": [ { "code": "85007", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18.2, "discounted_cash": 7.6, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4.75, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.8, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.05, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3.69 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3.89348 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.8, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.05, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.13, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.8, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4.598, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.72, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.05, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.05, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 8.65, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 10.45, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.8, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.08, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3.42, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.8, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.19 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.19 } ], "minimum": 3.05, "maximum": 10.45 } ] }, { "description": "HCT ISTAT (H&H ISTAT)", "code_information": [ { "code": "85014", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18.2, "discounted_cash": 4.74, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2.9625, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2.3 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2.428302 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3.1995, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2.8677, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.32, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 8.65, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3.792, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2.133, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2.03 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.19 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.19 } ], "minimum": 2.03, "maximum": 9.1 } ] }, { "description": "HEMATOCRIT", "code_information": [ { "code": "85014", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16.9, "discounted_cash": 4.74, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2.9625, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2.3 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2.428302 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3.1995, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2.8677, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.32, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 8.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3.792, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2.133, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2.03 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7.605 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.45 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.605 } ], "minimum": 2.03, "maximum": 8.45 } ] }, { "description": "HEMOGLOBIN HGB", "code_information": [ { "code": "85018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16.9, "discounted_cash": 4.74, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2.9625, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2.3 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2.428302 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3.1995, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2.8677, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.32, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 8.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 3.792, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 2.133, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 2.03 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7.605 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.45 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.605 } ], "minimum": 2.03, "maximum": 8.45 } ] }, { "description": "CBC AUTOMATED DIF", "code_information": [ { "code": "85025", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 55.9, "discounted_cash": 15.54, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.7125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.495964 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.4895, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.4017, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.61, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 21.37, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.432, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6.993, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6.65 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 25.155 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 27.95 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.155 } ], "minimum": 6.15, "maximum": 27.95 } ] }, { "description": "Complete cbc w/auto diff wbc", "code_information": [ { "code": "85025", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 55.9, "discounted_cash": 15.54, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.7125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.15 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.495964 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.4895, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.4017, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.61, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 21.37, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.432, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6.993, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6.65 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 25.155 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 27.95 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.155 } ], "minimum": 6.15, "maximum": 27.95 } ] }, { "description": "CBC W/ PLTS NO DIFF", "code_information": [ { "code": "85027", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 46.8, "discounted_cash": 12.94, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.0875, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.629162 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.7345, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.8287, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.34, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 22.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17.79, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.352, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5.823, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5.53 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 21.06 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.06 } ], "minimum": 5.53, "maximum": 23.4 } ] }, { "description": "CBC W/ NO DIFF", "code_information": [ { "code": "85027", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 46.8, "discounted_cash": 12.94, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.0875, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.629162 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.7345, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.8287, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.34, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 22.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 17.79, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.352, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5.823, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5.53 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 21.06 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.06 } ], "minimum": 5.53, "maximum": 23.4 } ] }, { "description": "RETIC COUNT AUTOMATED", "code_information": [ { "code": "85045", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 28.6, "discounted_cash": 7.98, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4.9875, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.99, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3.87 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4.088154 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.99, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.3865, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.99, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 4.8279, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.91, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 10.97, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.99, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.384, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3.591, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 3.99, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3.41 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 12.87 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.87 } ], "minimum": 3.41, "maximum": 14.3 } ] }, { "description": "ANTI THROMBIN III ACTIVITY", "code_information": [ { "code": "85300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.8, "discounted_cash": 23.7, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.8125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11.5 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12.14151 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.9975, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.3385, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.61, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 139.56, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 32.59, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.96, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 10.665, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 10.14 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 132.21 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 146.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 132.21 } ], "minimum": 10.14, "maximum": 146.9 } ] }, { "description": "ANTI THROMBIN III ANTIGEN", "code_information": [ { "code": "85301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 78, "discounted_cash": 21.62, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.5125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 10.49 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 11.075926 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.5935, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.0801, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.59, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 37.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 29.73, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.296, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 9.729, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.81, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 9.25 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 35.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 39 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 35.1 } ], "minimum": 9.25, "maximum": 39 } ] }, { "description": "PROTEIN C ACTIVITY", "code_information": [ { "code": "85303", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 84.5, "discounted_cash": 27.68, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.3, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.84, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.84, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 13.44 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 14.180464 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.84, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.84, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.684, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.84, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.7464, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.56, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.84, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.84, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 40.14, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 38.06, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.84, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.144, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 12.456, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.84, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 11.84 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 38.025 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 42.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 38.025 } ], "minimum": 11.84, "maximum": 42.25 } ] }, { "description": "PROTEIN S TOTAL", "code_information": [ { "code": "85305", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 84.5, "discounted_cash": 23.22, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.5125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.61, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 11.61, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11.27 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 11.895606 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.61, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 11.61, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.6735, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.61, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.0481, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.38, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 11.61, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 11.61, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 40.14, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 31.93, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.61, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.576, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 10.449, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.61, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 9.93 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 38.025 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 42.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 38.025 } ], "minimum": 9.93, "maximum": 42.25 } ] }, { "description": "PROTEIN S ACTIVITY", "code_information": [ { "code": "85306", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 84.5, "discounted_cash": 30.64, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.15, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 14.87 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 15.696872 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.682, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.5372, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15.01, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 40.14, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 42.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 24.512, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 13.788, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 15.32, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 13.1 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 38.025 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 42.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 38.025 } ], "minimum": 13.1, "maximum": 42.25 } ] }, { "description": "D-DIMER", "code_information": [ { "code": "85379", "type": "HCPCS" }, { "code": "305", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 41.6, "discounted_cash": 20.36, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.725, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 9.88 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 10.430428 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.743, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.3178, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.98, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 19.76, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 28, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.288, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 9.162, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.18, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 8.71 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 18.72 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.72 } ], "minimum": 8.71, "maximum": 28 } ] }, { "description": "PT/PROTHROMBIN TIME", "code_information": [ { "code": "85610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 28.6, "discounted_cash": 8.58, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.3625, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.29, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.29, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4.16 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4.395534 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.29, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.29, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.7915, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.29, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.1909, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.2, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.29, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.29, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 11.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.29, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.864, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3.861, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.29, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 12.87 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.87 } ], "minimum": 3.67, "maximum": 14.3 } ] }, { "description": "PT/INR TIME DAILY", "code_information": [ { "code": "85610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 28.6, "discounted_cash": 8.58, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.3625, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.29, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.29, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4.16 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4.395534 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.29, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.29, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.7915, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.29, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.1909, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.2, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.29, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.29, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 11.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.29, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.864, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3.861, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.29, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 12.87 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.87 } ], "minimum": 3.67, "maximum": 14.3 } ] }, { "description": "DRVVT", "code_information": [ { "code": "85613", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 149.5, "discounted_cash": 19.16, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.975, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.58, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.58, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 9.3 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 9.815668 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.58, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.58, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.933, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.58, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.5918, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.39, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.58, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.58, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 71.01, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 26.35, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.58, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.328, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 8.622, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.58, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 8.19 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 67.275 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 74.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 67.275 } ], "minimum": 8.19, "maximum": 74.75 } ] }, { "description": "SED RATE ESR", "code_information": [ { "code": "85651", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 78, "discounted_cash": 8.54, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.3375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4.15 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4.375042 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.7645, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.1667, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.18, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 37.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 11.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.832, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3.843, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3.65 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 35.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 39 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 35.1 } ], "minimum": 3.65, "maximum": 39 } ] }, { "description": "PTT-LUPUS ANTICOAGULANT", "code_information": [ { "code": "85705", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 189.8, "discounted_cash": 19.26, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.0375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.63, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 9.35 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 9.866898 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.63, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.0005, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.63, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.6523, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.44, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 90.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 26.48, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.63, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.408, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 8.667, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.63, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 8.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 85.41 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 94.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 85.41 } ], "minimum": 8.24, "maximum": 94.9 } ] }, { "description": "PTT", "code_information": [ { "code": "85730", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 44.2, "discounted_cash": 12.02, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.5125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5.83 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.157846 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.1135, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.2721, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.89, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 21, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 16.53, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.616, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5.409, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5.14 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 19.89 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.89 } ], "minimum": 5.14, "maximum": 22.1 } ] }, { "description": "PTT DAILY", "code_information": [ { "code": "85730", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 44.2, "discounted_cash": 12.02, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.5125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5.83 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.157846 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.1135, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.2721, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.89, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 21, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 16.53, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.616, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5.409, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5.14 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 19.89 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.89 } ], "minimum": 5.14, "maximum": 22.1 } ] }, { "description": "PTT-LA", "code_information": [ { "code": "85730", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 44.2, "discounted_cash": 12.02, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.5125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5.83 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.157846 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.1135, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.2721, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.89, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 21, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 16.53, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.616, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5.409, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5.14 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 19.89 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.89 } ], "minimum": 5.14, "maximum": 22.1 } ] }, { "description": "ANTI NUCLEAR ANTIBODY", "code_information": [ { "code": "86038", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 111.8, "discounted_cash": 24.18, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.1125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11.74 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12.387414 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.3215, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.6289, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.85, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 53.11, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 33.25, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.344, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 10.881, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.09, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 10.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 50.31 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 55.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 50.31 } ], "minimum": 6.01, "maximum": 55.9 } ] }, { "description": "TRANSFUSION REACTION INVESTIGATION", "code_information": [ { "code": "86078", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 253.5, "discounted_cash": 309.19, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 193.24375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 139.31 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 147.0301 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 208.70325, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 152.2, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 187.05995, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 149.16, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.01, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 120.41, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 418.55, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 247.352, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 139.1355, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.595, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 132.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 114.075 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 126.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 114.075 } ], "minimum": 6.01, "maximum": 418.55 } ] }, { "description": "C REACTIVE PROTEIN", "code_information": [ { "code": "86140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.7, "discounted_cash": 10.36, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.475, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5.03 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5.307428 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.993, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.2678, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.08, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.91, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14.25, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.288, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4.662, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.18, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4.43 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.965 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.85 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.965 } ], "minimum": 4.43, "maximum": 18.85 } ] }, { "description": "CARDIO CRP", "code_information": [ { "code": "86141", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 93.6, "discounted_cash": 25.9, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.1875, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 12.57 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 13.26857 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.4825, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.6695, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.69, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 44.46, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 35.61, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.72, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 11.655, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.95, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 11.08 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 42.12 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 46.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 42.12 } ], "minimum": 11.08, "maximum": 46.8 } ] }, { "description": "CARDIOLIPIN ANTIBODY", "code_information": [ { "code": "86147", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 78, "discounted_cash": 50.9, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 31.8125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 24.71 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 26.07607 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 34.3575, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 30.7945, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 24.94, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 37.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 69.99, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 40.72, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 22.905, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 25.45, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 21.77 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 35.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 39 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 35.1 } ], "minimum": 14.15, "maximum": 69.99 } ] }, { "description": "COMPLEMENT C4", "code_information": [ { "code": "86160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.7, "discounted_cash": 24, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11.65 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12.2952 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.2, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.52, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.76, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.91, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 33, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.2, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 10.26 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.965 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.85 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.965 } ], "minimum": 10.26, "maximum": 33 } ] }, { "description": "COMPLEMENT C3", "code_information": [ { "code": "86160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.7, "discounted_cash": 24, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11.65 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12.2952 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.2, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.52, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.76, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.91, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 33, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.2, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 10.26 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.965 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.85 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.965 } ], "minimum": 10.26, "maximum": 33 } ] }, { "description": "COMPLEMENT TOTAL CH50", "code_information": [ { "code": "86162", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 144.3, "discounted_cash": 40.64, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 25.4, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 20.32, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 20.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 19.73 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 20.819872 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 20.32, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 20.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 27.432, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 20.32, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 24.5872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 19.91, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 20.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 20.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 68.54, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 55.88, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 20.32, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 32.512, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 18.288, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 20.32, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 17.38 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 64.935 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 72.15 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 64.935 } ], "minimum": 17.38, "maximum": 72.15 } ] }, { "description": "ANTI dsDNA", "code_information": [ { "code": "86225", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 196.3, "discounted_cash": 27.48, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.175, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 13.34 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 14.078004 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 18.549, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.6254, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.47, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 93.24, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 37.79, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.984, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 12.366, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.74, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 88.335 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 98.15 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 88.335 } ], "minimum": 11.75, "maximum": 98.15 } ] }, { "description": "SJROGREN'S SSA", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 156, "discounted_cash": 35.86, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.4125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 17.41 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 18.371078 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 24.2055, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.6953, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.57, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 74.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 49.31, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 28.688, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 16.137, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 15.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 70.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 78 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 70.2 } ], "minimum": 14.15, "maximum": 78 } ] }, { "description": "SJROGREN'S SSB", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 156, "discounted_cash": 35.86, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.4125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 17.41 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 18.371078 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 24.2055, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.6953, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.57, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 74.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 49.31, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 28.688, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 16.137, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 15.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 70.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 78 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 70.2 } ], "minimum": 14.15, "maximum": 78 } ] }, { "description": "RNP", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 88.4, "discounted_cash": 35.86, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.4125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 17.41 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 18.371078 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 24.2055, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.6953, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.57, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 41.99, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 49.31, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 28.688, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 16.137, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 15.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 39.78 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 44.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 39.78 } ], "minimum": 14.15, "maximum": 49.31 } ] }, { "description": "ANTIEXTRACTABLE NUCLEAR AG(SMITH/RNP)", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 53.79, "discounted_cash": 35.86, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.4125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 17.41 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 18.371078 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 24.2055, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.6953, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.57, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 25.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 49.31, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 28.688, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 16.137, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 15.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 24.2055 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.895 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 24.2055 } ], "minimum": 14.15, "maximum": 49.31 } ] }, { "description": "ANTIHISTONE ANTIBODIES", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 82.58, "discounted_cash": 35.86, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.4125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 17.41 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 18.371078 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 24.2055, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.6953, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.57, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 39.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 49.31, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 28.688, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 16.137, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 15.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 37.161 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 41.29 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 37.161 } ], "minimum": 14.15, "maximum": 49.31 } ] }, { "description": "SCLERODERMA-70 AB", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 104, "discounted_cash": 35.86, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.4125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 17.41 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 18.371078 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 24.2055, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.6953, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.57, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 49.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 49.31, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 28.688, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 16.137, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 15.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 46.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 52 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 46.8 } ], "minimum": 14.15, "maximum": 52 } ] }, { "description": "SMITH ANTIBODY", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 88.4, "discounted_cash": 35.86, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.4125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 17.41 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 18.371078 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 24.2055, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.6953, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.57, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.15, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 41.99, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 49.31, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 28.688, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 16.137, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 17.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 15.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 39.78 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 44.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 39.78 } ], "minimum": 14.15, "maximum": 49.31 } ] }, { "description": "IMMUNOFIXATION", "code_information": [ { "code": "86334", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 183.3, "discounted_cash": 44.68, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 27.925, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 22.34, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 20.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 21.69 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 22.889564 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 22.34, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 20.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 30.159, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 22.34, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 27.0314, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.89, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 20.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 20.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 87.07, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 61.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 22.34, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 35.744, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 20.106, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 22.34, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 19.11 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 82.485 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 91.65 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 82.485 } ], "minimum": 19.11, "maximum": 91.65 } ] }, { "description": "RHEUMATOID ARTHRITIS FACTOR", "code_information": [ { "code": "86431", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 59.8, "discounted_cash": 11.34, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.0875, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.67, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.67, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5.809482 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.67, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.67, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.6545, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.67, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.8607, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.56, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.67, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.67, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 28.41, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 15.59, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.67, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.072, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5.103, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.67, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4.85 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 26.91 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.91 } ], "minimum": 4.85, "maximum": 29.9 } ] }, { "description": "QUANTIFERON GOLD", "code_information": [ { "code": "86480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 468.68, "discounted_cash": 123.96, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 77.475, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 61.98, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 61.98, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 60.17 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 63.504708 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 61.98, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 61.98, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 83.673, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 61.98, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 74.9958, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 60.74, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 61.98, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 61.98, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 222.62, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 170.45, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 61.98, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 99.168, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 55.782, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 61.98, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 53.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 210.906 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 234.34 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 210.906 } ], "minimum": 53.02, "maximum": 234.34 } ] }, { "description": "RPR", "code_information": [ { "code": "86592", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.7, "discounted_cash": 8.54, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.3375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4.15 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4.375042 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.7645, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.1667, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.18, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.08, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 11.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.832, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3.843, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3.65 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 22.815 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.35 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.815 } ], "minimum": 3.65, "maximum": 25.35 } ] }, { "description": "PNEUMOCOCCAL ANTIBODIES (#) IGG SEROTYPE", "code_information": [ { "code": "86609", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 106.34, "discounted_cash": 25.76, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 13.03 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 13.196848 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.388, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.5848, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.6224, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 50.5115, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 35.42, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.608, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 11.592, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.88 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 11.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 47.853 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 53.17 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 47.853 } ], "minimum": 11.02, "maximum": 53.17 } ] }, { "description": "HEP B CORE TOTAL", "code_information": [ { "code": "86704", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 87.1, "discounted_cash": 24.1, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.0625, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12.34643 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.2675, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.5805, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.81, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 41.37, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 33.14, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.28, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 10.845, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.05, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 10.31 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 39.195 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 43.55 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 39.195 } ], "minimum": 10.31, "maximum": 43.55 } ] }, { "description": "HEP B SURFACE ANTIBODY", "code_information": [ { "code": "86706", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 78, "discounted_cash": 21.48, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.425, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 10.43 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 11.004204 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.499, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.9954, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.53, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 37.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 29.54, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.184, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 9.666, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.74, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 9.19 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 35.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 39 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 35.1 } ], "minimum": 9.19, "maximum": 39 } ] }, { "description": "MUMPS, IGG", "code_information": [ { "code": "86735", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 87.1, "discounted_cash": 26.1, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.3125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.05, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.05, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 12.67 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 13.37103 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.05, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.05, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.6175, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.05, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.7905, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.79, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.05, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.05, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 41.37, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 35.89, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.05, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.88, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 11.745, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.05, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 11.16 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 39.195 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 43.55 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 39.195 } ], "minimum": 11.16, "maximum": 43.55 } ] }, { "description": "RUBELLA TITER", "code_information": [ { "code": "86762", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 104, "discounted_cash": 28.78, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.9875, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.39, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 13.97 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 14.743994 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.4265, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.4119, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.1, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 49.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 39.57, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 23.024, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 12.951, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12.31 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 46.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 52 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 46.8 } ], "minimum": 12.31, "maximum": 52 } ] }, { "description": "MEASLES, IGG", "code_information": [ { "code": "86765", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 87.1, "discounted_cash": 25.76, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 12.5 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 13.196848 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.388, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.5848, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.62, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 41.37, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 35.42, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.608, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 11.592, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 11.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 39.195 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 43.55 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 39.195 } ], "minimum": 11.02, "maximum": 43.55 } ] }, { "description": "FTA-ABS", "code_information": [ { "code": "86780", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 41.6, "discounted_cash": 26.48, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.55, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.34, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 12.85 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 13.565704 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.34, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.874, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.0204, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.98, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.34, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.34, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 19.76, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 36.41, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 21.184, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 11.916, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.24, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 11.33 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 18.72 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.72 } ], "minimum": 11.33, "maximum": 36.41 } ] }, { "description": "VARICELLA ZOSTER AB, IGG", "code_information": [ { "code": "86787", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 87.1, "discounted_cash": 25.76, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.1, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 12.5 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 13.196848 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.388, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.5848, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.62, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 41.37, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 35.42, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.608, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 11.592, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.88, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 11.02 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 39.195 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 43.55 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 39.195 } ], "minimum": 11.02, "maximum": 43.55 } ] }, { "description": "HEPATITIS C ANTIBODY REFLEX TO RNA (NAA)", "code_information": [ { "code": "86803", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 104, "discounted_cash": 28.54, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.8375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.27, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.27, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 13.85 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 14.621042 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.27, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.27, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.2645, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.27, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.2667, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.98, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.27, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.27, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 49.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 39.24, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.27, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.832, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 12.843, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.27, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 12.21 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 46.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 52 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 46.8 } ], "minimum": 12.21, "maximum": 52 } ] }, { "description": "BB.TBC. ANTIBODY SCREEN", "code_information": [ { "code": "86850", "type": "HCPCS" }, { "code": "302", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 205.4, "discounted_cash": 94.5712768, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 59.107048, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 9.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 10.010342 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 63.83561184, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.45, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 57.21562246, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 46.5, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 97.57, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 130.49, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 75.65702144, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 42.55707456, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 40.45 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 92.43 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 102.7 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 92.43 } ], "minimum": 6.74, "maximum": 130.49 } ] }, { "description": "BB ANTIBODY SCREEN", "code_information": [ { "code": "86850", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 205.4, "discounted_cash": 94.5712768, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 59.107048, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 9.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 10.010342 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 63.83561184, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.45, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 57.21562246, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 46.5, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.74, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 97.57, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 130.49, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 75.65702144, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 42.55707456, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 40.45 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 92.43 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 102.7 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 92.43 } ], "minimum": 6.74, "maximum": 130.49 } ] }, { "description": "BB.TBC. ADSORPTION (BLOOD)", "code_information": [ { "code": "86870", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 694.62, "discounted_cash": 650.5061472, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 406.566342, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.86, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 275.13 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 290.381886 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.86, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 439.0916494, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 319.49, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 393.5562191, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 313.1, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.86, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.86, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 329.94, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 878.6, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 520.4049178, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 292.7277662, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 278.22 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 312.579 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 347.31 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 312.579 } ], "minimum": 43.86, "maximum": 878.6 } ] }, { "description": "BB.TBC. PANEL ROUTINE", "code_information": [ { "code": "86870", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 126.1, "discounted_cash": 650.5061472, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 406.566342, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.86, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 275.13 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 290.381886 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.86, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 439.0916494, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 319.49, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 393.5562191, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 313.1, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.86, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 43.86, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 59.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 878.6, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 520.4049178, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 292.7277662, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 278.22 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 56.745 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 63.05 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 56.745 } ], "minimum": 43.86, "maximum": 878.6 } ] }, { "description": "BB.TBC. DIRECT ANTIGLOBULIN TEST", "code_information": [ { "code": "86880", "type": "HCPCS" }, { "code": "302", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 126.1, "discounted_cash": 107.0588064, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 66.911754, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 53.5294032, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5.23 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5.522594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 53.5294032, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 72.26469432, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 52.76, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 64.77057787, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 51.7, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 59.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 145.09, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 53.5294032, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 85.64704512, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 48.17646288, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 53.5294032, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 45.79 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 56.745 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 63.05 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 56.745 } ], "minimum": 5.23, "maximum": 145.09 } ] }, { "description": "BB ABO PANEL, SEROLOGIC", "code_information": [ { "code": "86900", "type": "HCPCS" }, { "code": "302", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.9, "discounted_cash": 241.4551776, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 150.909486, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 120.7275888, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3.063554 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 120.7275888, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 162.9822449, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 114.48, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 146.0803824, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 112.19, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 69.78, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 314.82, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 120.7275888, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 193.1641421, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 108.6548299, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 120.7275888, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 103.27 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 66.105 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 73.45 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 66.105 } ], "minimum": 2.9, "maximum": 314.82 } ] }, { "description": "BB.TBC. RH FACTOR", "code_information": [ { "code": "86901", "type": "HCPCS" }, { "code": "302", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 132.6, "discounted_cash": 67.7843712, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 42.365232, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 33.8921856, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3.063554 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 33.8921856, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 45.75445056, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 34.86, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 41.00954458, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 34.16, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 62.99, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 95.87, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 33.8921856, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 54.22749696, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 30.50296704, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 33.8921856, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 28.99 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 59.67 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 66.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 59.67 } ], "minimum": 2.9, "maximum": 95.87 } ] }, { "description": "BB RH FACTOR", "code_information": [ { "code": "86901", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 132.6, "discounted_cash": 67.7843712, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 42.365232, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 33.8921856, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2.9 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3.063554 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 33.8921856, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 45.75445056, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 34.86, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 41.00954458, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 34.16, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.99, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 62.99, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 95.87, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 33.8921856, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 54.22749696, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 30.50296704, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 33.8921856, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 28.99 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 59.67 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 66.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 59.67 } ], "minimum": 2.9, "maximum": 95.87 } ] }, { "description": "BB.TBC. ANTIGEN SCREEN GROUP 1", "code_information": [ { "code": "86902", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 36.61, "discounted_cash": 650.5061472, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 406.566342, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.97, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.16 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.50621 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.97, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 439.0916494, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 319.49, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 393.5562191, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 313.1, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.97, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.97, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.39, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 878.6, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 520.4049178, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 292.7277662, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 278.22 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.4745 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.305 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.4745 } ], "minimum": 4.97, "maximum": 878.6 } ] }, { "description": "BB.TBC. ANTIGEN SCREEN GROUP 2", "code_information": [ { "code": "86902", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 36.61, "discounted_cash": 650.5061472, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 406.566342, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.97, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.16 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.50621 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.97, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 439.0916494, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 319.49, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 393.5562191, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 313.1, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.97, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.97, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.39, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 878.6, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 520.4049178, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 292.7277662, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 278.22 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.4745 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.305 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.4745 } ], "minimum": 4.97, "maximum": 878.6 } ] }, { "description": "BB.TBC. ANTIGEN SCREEN GROUP 3", "code_information": [ { "code": "86902", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 36.61, "discounted_cash": 650.5061472, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 406.566342, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.97, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.16 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.50621 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.97, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 439.0916494, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 319.49, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 393.5562191, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 313.1, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.97, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.97, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.39, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 878.6, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 520.4049178, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 292.7277662, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 278.22 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.4745 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.305 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.4745 } ], "minimum": 4.97, "maximum": 878.6 } ] }, { "description": "BB.TBC. AG TYPING", "code_information": [ { "code": "86906", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 74.15, "discounted_cash": 67.7843712, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 42.365232, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 33.8921856, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.75, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 7.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 7.94065 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 33.8921856, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.75, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 45.75445056, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 34.86, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 41.00954458, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 34.16, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.75, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.75, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 35.22, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 95.87, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 33.8921856, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 54.22749696, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 30.50296704, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 33.8921856, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 28.99 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 33.3675 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 37.075 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 33.3675 } ], "minimum": 7.52, "maximum": 95.87 } ] }, { "description": "BB CROSSMATCH IMMEDIATE SPIN, GEL", "code_information": [ { "code": "86920", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.6, "discounted_cash": 309.1862592, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 193.241412, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 51.38, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 139.31 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 147.0301 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 51.38, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 208.700725, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 152.2, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 187.0576868, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 149.16, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 51.38, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 51.38, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 316.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 418.55, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 247.3490074, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 139.1338166, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 132.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 299.52 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 332.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 299.52 } ], "minimum": 51.38, "maximum": 418.55 } ] }, { "description": "BB.TBC. COMPATABILITY TESTING", "code_information": [ { "code": "86922", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.6, "discounted_cash": 309.1862592, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 193.241412, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 48.94, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 139.31 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 147.0301 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 48.94, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 208.700725, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 152.2, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 187.0576868, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 149.16, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 48.94, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 48.94, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 316.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 418.55, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 247.3490074, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 139.1338166, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 132.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 299.52 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 332.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 299.52 } ], "minimum": 48.94, "maximum": 418.55 } ] }, { "description": "BB CROSSMATCH IGG, GEL", "code_information": [ { "code": "86922", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.6, "discounted_cash": 309.1862592, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 193.241412, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 48.94, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 139.31 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 147.0301 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 48.94, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 208.700725, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 152.2, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 187.0576868, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 149.16, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 48.94, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 48.94, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 316.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 418.55, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 247.3490074, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 139.1338166, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 132.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 299.52 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 332.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 299.52 } ], "minimum": 48.94, "maximum": 418.55 } ] }, { "description": "BB.TBC. NEUTRALIZATION", "code_information": [ { "code": "86977", "type": "HCPCS" }, { "code": "302", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 457, "discounted_cash": 309.1862592, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 193.241412, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 139.31 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 147.0301 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 208.700725, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 152.2, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 187.0576868, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 149.16, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.26, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 217.08, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 418.55, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 247.3490074, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 139.1338166, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 132.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 205.65 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 228.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 205.65 } ], "minimum": 8.26, "maximum": 418.55 } ] }, { "description": "SPECIMEN CONCENTRATION", "code_information": [ { "code": "87015", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 49.19, "discounted_cash": 13.36, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.35, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.844328 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.018, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.0828, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.55, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 23.37, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 18.37, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.688, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6.012, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.68, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5.71 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 22.1355 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 24.595 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.1355 } ], "minimum": 5.71, "maximum": 24.595 } ] }, { "description": "CULTURE BLOOD", "code_information": [ { "code": "87040", "type": "HCPCS" }, { "code": "306", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 75.4, "discounted_cash": 20.64, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.9, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 10.02 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 10.573872 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.932, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 14.13, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.4872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.85, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 35.82, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 38.86, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.512, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 9.288, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 8.83 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 33.93 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 37.7 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 33.93 } ], "minimum": 8.83, "maximum": 38.86 } ] }, { "description": "CULTURE BACTERIA OTH", "code_information": [ { "code": "87070", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 63.44, "discounted_cash": 17.24, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.775, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 8.37 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 8.832052 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.637, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.4302, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.45, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 30.13, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 23.71, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.792, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7.758, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.62, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7.37 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 28.548 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 31.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 28.548 } ], "minimum": 7.37, "maximum": 31.72 } ] }, { "description": "CULTURE ANAEROBIC", "code_information": [ { "code": "87075", "type": "HCPCS" }, { "code": "306", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 68.9, "discounted_cash": 18.94, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.8375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 9.19 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 9.702962 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.7845, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.4587, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.28, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 32.73, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 26.04, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.152, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 8.523, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 9.47, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 8.1 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 31.005 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 34.45 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 31.005 } ], "minimum": 8.1, "maximum": 34.45 } ] }, { "description": "ORGANISM ID ANAEROBE", "code_information": [ { "code": "87076", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 58.5, "discounted_cash": 16.16, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.1, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 7.84 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 8.278768 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.908, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.7768, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.92, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 27.79, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.928, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7.272, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6.91 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 26.325 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.325 } ], "minimum": 6.91, "maximum": 29.25 } ] }, { "description": "ORGANISM ID BACTERIAL", "code_information": [ { "code": "87077", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 58.5, "discounted_cash": 16.16, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.1, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 7.84 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 8.278768 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.908, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.7768, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.92, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 27.79, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 22.22, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.928, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7.272, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.08, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6.91 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 26.325 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.325 } ], "minimum": 6.91, "maximum": 29.25 } ] }, { "description": "MRSA SCREEN ONLY", "code_information": [ { "code": "87081", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 65, "discounted_cash": 13.26, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.2875, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.63, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.63, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.44 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.793098 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.63, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.63, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.9505, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.63, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.0223, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.5, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.63, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.63, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 30.88, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 18.23, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.63, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.608, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5.967, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 6.63, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 5.67 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 29.25 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 32.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.25 } ], "minimum": 5.67, "maximum": 32.5 } ] }, { "description": "CULTURE URINE ROUTINE", "code_information": [ { "code": "87086", "type": "HCPCS" }, { "code": "306", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 58.5, "discounted_cash": 16.14, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.0875, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 7.83 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 8.268522 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.8945, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.7647, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.91, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 27.79, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 22.19, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.912, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7.263, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.07, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6.9 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 26.325 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.325 } ], "minimum": 6.9, "maximum": 29.25 } ] }, { "description": "PRESUMPTIVE ID", "code_information": [ { "code": "87088", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 58.5, "discounted_cash": 16.18, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.1125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 7.85 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 8.289014 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.9215, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.7889, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.93, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 27.79, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 22.25, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.944, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7.281, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.09, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6.92 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 26.325 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.325 } ], "minimum": 6.92, "maximum": 29.25 } ] }, { "description": "CULTURE FUNGAL AND KOH", "code_information": [ { "code": "87102", "type": "HCPCS" }, { "code": "306", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 52, "discounted_cash": 16.82, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.5125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.41, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.41, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 8.16 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 8.616886 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.41, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.41, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.3535, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.41, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.1761, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.24, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.41, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.41, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 23.13, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.41, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.456, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7.569, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.41, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7.19 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 23.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 26 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.4 } ], "minimum": 7.19, "maximum": 26 } ] }, { "description": "CULTURE MYCOBACTERIUM", "code_information": [ { "code": "87116", "type": "CPT" }, { "code": "306", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 61.2, "discounted_cash": 21.6, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.5, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 10.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 11.06568 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.58, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.068, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.58, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 29.07, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 29.7, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.28, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 9.72, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 9.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 27.54 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 30.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 27.54 } ], "minimum": 9.24, "maximum": 30.6 } ] }, { "description": "CULTURE AFB", "code_information": [ { "code": "87116", "type": "HCPCS" }, { "code": "306", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 61.2, "discounted_cash": 21.6, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.5, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 10.48 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 11.06568 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.58, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.068, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.58, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 29.07, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 29.7, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.28, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 9.72, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.8, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 9.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 27.54 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 30.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 27.54 } ], "minimum": 9.24, "maximum": 30.6 } ] }, { "description": "SUSCEPTIBILITY", "code_information": [ { "code": "87186", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.7, "discounted_cash": 17.3, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.8125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 8.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 8.86279 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.6775, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10.4665, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.48, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.08, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 23.79, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.84, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7.785, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8.65, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 7.4 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 22.815 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.35 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.815 } ], "minimum": 7.4, "maximum": 25.35 } ] }, { "description": "GRAM STAIN", "code_information": [ { "code": "87205", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 31.46, "discounted_cash": 8.54, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.3375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4.15 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4.375042 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.7645, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 5.1667, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.18, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 14.94, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 11.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.832, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 3.843, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 4.27, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 3.65 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 14.157 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.73 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.157 } ], "minimum": 3.65, "maximum": 15.73 } ] }, { "description": "AFB SMEAR", "code_information": [ { "code": "87206", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 39.57, "discounted_cash": 10.78, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.7375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5.23 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5.522594 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.2765, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.5219, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.28, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 18.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 14.82, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.624, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4.851, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4.61 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 17.8065 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.785 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.8065 } ], "minimum": 4.61, "maximum": 19.785 } ] }, { "description": "C DIFF TOXINS A & B, EIA", "code_information": [ { "code": "87324", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 143, "discounted_cash": 23.96, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.975, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11.63 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 12.274708 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.173, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 14.4958, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.74, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 67.93, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 32.95, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 19.168, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 10.782, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 11.98, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 10.25 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 64.35 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 71.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 64.35 } ], "minimum": 10.25, "maximum": 71.5 } ] }, { "description": "HBV S AG", "code_information": [ { "code": "87340", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 75.4, "discounted_cash": 20.66, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.9125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 10.03 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 10.584118 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13.9455, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 12.4993, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.12, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 35.82, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 28.41, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.528, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 9.297, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 10.33, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 8.84 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 33.93 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 37.7 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 33.93 } ], "minimum": 8.84, "maximum": 37.7 } ] }, { "description": "NEISSERIA GONORRHOEA", "code_information": [ { "code": "87590", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 145.6, "discounted_cash": 53.76, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 33.6, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 26.88, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 26.88, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 26.1 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 27.541248 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 26.88, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 26.88, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 36.288, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 26.88, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 32.5248, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 26.34, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 26.88, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 26.88, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 69.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 73.92, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 26.88, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 43.008, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 24.192, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 26.88, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 22.99 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 65.52 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 72.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 65.52 } ], "minimum": 22.99, "maximum": 73.92 } ] }, { "description": "INFLUENZA A & B, SWAB", "code_information": [ { "code": "87804", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 91, "discounted_cash": 33.1, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.6875, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.55, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.18, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 16.07 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 16.95713 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.55, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.18, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 22.3425, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.55, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.0255, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.22, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.18, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.18, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 43.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 45.51, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.55, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 26.48, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 14.895, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 16.55, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 14.16 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 40.95 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 45.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 40.95 } ], "minimum": 14.16, "maximum": 45.51 } ] }, { "description": "RESPIRATORY SYNCYTIAL VIRUS ANTIGEN, RSV", "code_information": [ { "code": "87807", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 84.86, "discounted_cash": 26.2, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 16.375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.1, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.1, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 12.72 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 13.42226 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.1, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.1, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 17.685, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.1, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 15.851, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 12.84, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.1, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.1, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 40.31, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 36.03, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.1, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 20.96, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 11.79, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 13.1, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 11.21 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 38.187 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 42.43 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 38.187 } ], "minimum": 11.21, "maximum": 42.43 } ] }, { "description": "CYTOPATH, CELL ENHANCE", "code_information": [ { "code": "88112", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 223.18, "discounted_cash": 94.5712768, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 59.107048, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 57.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 48.03 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 50.686962 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 57.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 63.83561184, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.45, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 57.21562246, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 46.5, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 57.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 57.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 106.01, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 130.49, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 75.65702144, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 42.55707456, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 40.45 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 100.431 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 111.59 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 100.431 } ], "minimum": 40.45, "maximum": 130.49 } ] }, { "description": "CYTO PATH FISH", "code_information": [ { "code": "88120", "type": "HCPCS" }, { "code": "310", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 585, "discounted_cash": 309.1862592, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 193.241412, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 297.98, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 139.31 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 147.0301 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 297.98, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 208.700725, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 152.2, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 187.0576868, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 149.16, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 297.98, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 297.98, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 277.88, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 418.55, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 247.3490074, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 139.1338166, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 132.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 263.25 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 292.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 263.25 } ], "minimum": 132.24, "maximum": 418.55 } ] }, { "description": "PATH - SURG GROSS EXAM L1", "code_information": [ { "code": "88300", "type": "HCPCS" }, { "code": "310", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 108.42, "discounted_cash": 52.490256, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 32.80641, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 26.245128, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.53, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 22.32 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 23.555554 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 26.245128, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.53, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 35.4309228, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.75, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 31.75660488, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 21.32, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.53, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 10.53, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 51.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 59.81, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 26.245128, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 41.9922048, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 23.6206152, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 26.245128, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 22.45 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 48.789 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 54.21 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 48.789 } ], "minimum": 10.53, "maximum": 59.81 } ] }, { "description": "PATH - SURG GROSS & MICRO L2", "code_information": [ { "code": "88302", "type": "HCPCS" }, { "code": "310", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 224.85, "discounted_cash": 67.7843712, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 42.365232, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 33.8921856, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 24.46, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 22.32 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 23.555554 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 33.8921856, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 24.46, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 45.75445056, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 34.86, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 41.00954458, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 34.16, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 24.46, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 24.46, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 106.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 95.87, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 33.8921856, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 54.22749696, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 30.50296704, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 33.8921856, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 28.99 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 101.1825 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 112.425 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 101.1825 } ], "minimum": 22.32, "maximum": 112.425 } ] }, { "description": "PATH - SURG GROSS & MICRO L3", "code_information": [ { "code": "88304", "type": "HCPCS" }, { "code": "310", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 232.6, "discounted_cash": 94.5712768, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 59.107048, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.09, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 48.03 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 50.686962 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.09, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 63.83561184, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.45, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 57.21562246, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 46.5, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.09, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 35.09, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 110.49, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 130.49, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 75.65702144, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 42.55707456, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 40.45 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 104.67 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 116.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 104.67 } ], "minimum": 35.09, "maximum": 130.49 } ] }, { "description": "PATH - SURG GROSS & MICRO L4", "code_information": [ { "code": "88305", "type": "HCPCS" }, { "code": "310", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 317.98, "discounted_cash": 94.5712768, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 59.107048, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 49.42, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 48.03 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 50.686962 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 49.42, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 63.83561184, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.45, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 57.21562246, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 46.5, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 49.42, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 49.42, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 151.04, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 130.49, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 75.65702144, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 42.55707456, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 40.45 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 143.091 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 158.99 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 143.091 } ], "minimum": 40.45, "maximum": 158.99 } ] }, { "description": "PATH - SURG GROSS & MICRO L5", "code_information": [ { "code": "88307", "type": "HCPCS" }, { "code": "310", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 709.12, "discounted_cash": 650.5061472, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 406.566342, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 70.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 275.13 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 290.381886 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 70.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 439.0916494, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 319.49, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 393.5562191, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 313.1, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 70.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 70.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 336.83, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 878.6, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 520.4049178, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 292.7277662, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 278.22 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 319.104 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 354.56 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 319.104 } ], "minimum": 70.7, "maximum": 878.6 } ] }, { "description": "PATH - SURG GROSS & MICRO L6", "code_information": [ { "code": "88309", "type": "HCPCS" }, { "code": "310", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 986.54, "discounted_cash": 1462.142282, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 913.838926, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 731.0711408, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 70.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 609.86 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 643.65372 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 731.0711408, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 70.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 986.9460401, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 725.54, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 884.5960804, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 711.03, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 70.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 70.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.61, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1995.24, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 731.0711408, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1169.713825, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 657.9640267, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 731.0711408, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 625.36 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 443.943 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 493.27 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 443.943 } ], "minimum": 70.7, "maximum": 1995.24 } ] }, { "description": "PATH - DECALCIFICATION", "code_information": [ { "code": "88311", "type": "HCPCS" }, { "code": "310", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 32.34, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.16, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.02, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.7, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 15.36, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 19.69, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 14.553 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.17 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.553 } ], "minimum": 0.01, "maximum": 19.69 } ] }, { "description": "PATH - SPECIAL STAINS GRP 1", "code_information": [ { "code": "88312", "type": "HCPCS" }, { "code": "310", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 308.67, "discounted_cash": 94.5712768, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 59.107048, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 48.03 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 50.686962 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 63.83561184, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.45, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 57.21562246, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 46.5, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 12.02, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 146.62, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 130.49, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 75.65702144, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 42.55707456, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.2856384, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 40.45 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 138.9015 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 154.335 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 138.9015 } ], "minimum": 12.02, "maximum": 154.335 } ] }, { "description": "PATH -EACH ADDITIONAL SINGLE AB STAIN", "code_information": [ { "code": "88341", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 135.2, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 59.94, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 66.66 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 70.349036 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 59.94, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 58.99, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 57.81, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 59.94, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 59.94, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 64.22, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 162.22, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 60.84 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 67.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 60.84 } ], "minimum": 57.81, "maximum": 162.22 } ] }, { "description": "PATH - IMMUNO STAIN, INITIAL ANTIBODY ST", "code_information": [ { "code": "88342", "type": "HCPCS" }, { "code": "310", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 182, "discounted_cash": 309.1862592, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 193.241412, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 49.84, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 139.31 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 147.0301 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 49.84, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 208.700725, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 152.2, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 187.0576868, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 149.16, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 49.84, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 49.84, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 86.45, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 418.55, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 247.3490074, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 139.1338166, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 154.5931296, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 132.24 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 81.9 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 91 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 81.9 } ], "minimum": 49.84, "maximum": 418.55 } ] }, { "description": "PATH - EACH MULTIPLEX AB STAIN", "code_information": [ { "code": "88344", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 135.2, "discounted_cash": 650.5061472, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 406.566342, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 103.69, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 275.13 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 290.381886 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 103.69, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 439.0916494, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 319.49, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 393.5562191, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 313.1, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 103.69, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 103.69, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 64.22, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 878.6, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 520.4049178, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 292.7277662, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.2530736, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 278.22 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 60.84 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 67.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 60.84 } ], "minimum": 60.84, "maximum": 878.6 } ] }, { "description": "BODY FLUID CELL COUNT", "code_information": [ { "code": "89051", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 33.8, "discounted_cash": 11.2, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 5.66 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 5.73776 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.56, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.776, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.488, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.055, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 16.5, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.96, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5.04, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.6, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 4.79 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.21 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.21 } ], "minimum": 4.79, "maximum": 16.9 } ] }, { "description": "CRYSTAL IDENTIFICATION, BODY FLUID", "code_information": [ { "code": "89060", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 71.5, "discounted_cash": 14.66, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.1625, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.33, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.33, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 7.42 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 7.510318 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.33, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.33, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.8955, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.33, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 8.8693, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.1834, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.33, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 7.33, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 33.9625, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 19.25, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.33, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11.728, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 6.597, "additional_payer_notes": "90% of medicare" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 7.33, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6.27 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 32.175 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 35.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 32.175 } ], "minimum": 6.27, "maximum": 35.75 } ] }, { "description": "EKG 12 LEAD, INITIAL", "code_information": [ { "code": "93005", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 131.3, "discounted_cash": 107.0588064, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 66.911754, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 53.5294032, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 19.58996, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 53.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 56.363246 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 53.5294032, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 19.58996, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 72.26469432, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 52.76, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 64.77057787, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 51.7, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 19.58996, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 19.58996, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 62.37, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 145.09, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 53.5294032, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 85.64704512, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 64.61, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 53.5294032, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 59.4 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 59.085 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 65.65 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 59.085 } ], "minimum": 19.58996, "maximum": 145.09 } ] }, { "description": "EKG 12 LEAD REPEAT", "code_information": [ { "code": "93005", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 29.9, "discounted_cash": 107.0588064, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 66.911754, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 53.5294032, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.46108, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 53.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 56.363246 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 53.5294032, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.46108, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 72.26469432, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 52.76, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 64.77057787, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 51.7, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.46108, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.46108, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 14.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 145.09, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 53.5294032, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 85.64704512, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 64.61, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 53.5294032, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 59.4 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 13.455 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.95 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.455 } ], "minimum": 4.46108, "maximum": 145.09 } ] }, { "description": "EKG 12 LEAD REPEAT-DIFF DR", "code_information": [ { "code": "93005", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 88.4, "discounted_cash": 107.0588064, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 66.911754, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 53.5294032, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.18928, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 53.4 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 56.363246 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 53.5294032, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.18928, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 72.26469432, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 52.76, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 64.77057787, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 51.7, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.18928, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.18928, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 41.99, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 145.09, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 53.5294032, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 85.64704512, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 64.61, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 53.5294032, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 59.4 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 39.78 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 44.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 39.78 } ], "minimum": 13.18928, "maximum": 145.09 } ] }, { "description": "US ECHO COMP W/ SPEC AND CF DOPP", "code_information": [ { "code": "93306", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1804, "discounted_cash": 991.63064, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 619.76915, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 495.81532, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 269.1568, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 467.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 493.426868 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 495.81532, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 269.1568, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 669.350682, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 486.98, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 599.9365372, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 477.24, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 269.1568, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 269.1568, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 856.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1339.2, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 495.81532, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 793.304512, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 598.47, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 495.81532, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 548.3 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 811.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 902 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 811.8 } ], "minimum": 269.1568, "maximum": 1339.2 } ] }, { "description": "US ECHO TEE", "code_information": [ { "code": "93312", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2400, "discounted_cash": 991.63064, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 619.76915, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 495.81532, "additional_payer_notes": "100%_of_Medicare_fee_schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 358.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 467.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 493.426868 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 495.81532, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 358.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 669.350682, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 486.98, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 599.9365372, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 477.24, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 358.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 358.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1140, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1339.2, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 495.81532, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 793.304512, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 598.47, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 495.81532, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 548.3 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1080 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1200 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1080 } ], "minimum": 358.08, "maximum": 1339.2 } ] }, { "description": "US DOPPLER ECHO COMP", "code_information": [ { "code": "93320", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1208, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 180.2336, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 52.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 55.133726 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 180.2336, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 180.2336, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 180.2336, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 573.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 543.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 604 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 543.6 } ], "minimum": 52.24, "maximum": 604 } ] }, { "description": "US DUP EXTRACRAN ART COMP BIL", "code_information": [ { "code": "93880", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 869, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 129.6548, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 129.6548, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 214.69, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 210.4, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 129.6548, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 129.6548, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 412.78, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 590.4, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.33, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 391.05 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 434.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 391.05 } ], "minimum": 129.6548, "maximum": 590.4 } ] }, { "description": "US DUPLEX EXT VEINS BILAT", "code_information": [ { "code": "93970", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 620, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 92.504, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 92.504, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 214.69, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 210.4, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 92.504, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 92.504, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 294.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 590.4, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.33, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 279 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 310 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 279 } ], "minimum": 92.504, "maximum": 590.4 } ] }, { "description": "US DUP EXT VEINS RT", "code_information": [ { "code": "93971", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 398, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 59.3816, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 59.3816, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.45, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.56, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 59.3816, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 59.3816, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 189.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 179.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 199 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 179.1 } ], "minimum": 59.3816, "maximum": 259.74 } ] }, { "description": "US DUP EXT VEINS LT", "code_information": [ { "code": "93971", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 398, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 59.3816, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 59.3816, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.45, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.56, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 59.3816, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 59.3816, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 189.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 179.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 199 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 179.1 } ], "minimum": 59.3816, "maximum": 259.74 } ] }, { "description": "US DUP ART IN/VEN OUT COMP", "code_information": [ { "code": "93975", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 803, "discounted_cash": 433.0135264, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 270.633454, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.8076, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 226.24 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 238.772784 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.8076, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 292.2841303, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 214.69, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 261.9731835, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 210.4, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.8076, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.8076, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 381.43, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 590.4, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 346.4108211, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 261.33, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 216.5067632, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 241.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 361.35 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 401.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 361.35 } ], "minimum": 119.8076, "maximum": 590.4 } ] }, { "description": "US DUP ART IN/VEN OUT LTD", "code_information": [ { "code": "93976", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 803, "discounted_cash": 189.7287392, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.580462, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.8076, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 108.81 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 114.837168 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.8076, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.066899, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.45, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 114.7858872, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 92.56, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.8076, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.8076, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 381.43, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 259.74, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 151.7829914, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 114.5, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 94.8643696, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 106.34 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 361.35 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 401.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 361.35 } ], "minimum": 92.56, "maximum": 401.5 } ] }, { "description": "INCENTIVE SPIROMETRY TX", "code_information": [ { "code": "94010", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 58.5, "discounted_cash": 391.856192, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 244.91012, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 195.928096, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.7282, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 134.31 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 141.75341 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 195.928096, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.7282, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 264.5029296, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 138.96, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 237.0729962, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 136.18, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.7282, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.7282, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 27.79, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 382.14, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 195.928096, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 313.4849536, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 236.49, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 195.928096, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 156.46 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 26.325 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.325 } ], "minimum": 8.7282, "maximum": 382.14 } ] }, { "description": "HAND HELD NEB TREATMENT INITIAL", "code_information": [ { "code": "94640", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 204.1, "discounted_cash": 397.3983104, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 248.373944, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 30.45172, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 178.59 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 188.485416 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 30.45172, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 268.2438595, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 180.64, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 240.4259778, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 177.03, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 30.45172, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 30.45172, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 96.95, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 496.76, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 317.9186483, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 239.84, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 203.39 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 91.845 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 102.05 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 91.845 } ], "minimum": 30.45172, "maximum": 496.76 } ] }, { "description": "HAND HELD NEB TX SUBS", "code_information": [ { "code": "94640", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 184.6, "discounted_cash": 397.3983104, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 248.373944, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 27.54232, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 178.59 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 188.485416 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 27.54232, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 268.2438595, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 180.64, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 240.4259778, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 177.03, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 27.54232, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 27.54232, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 87.69, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 496.76, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 317.9186483, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 239.84, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 203.39 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 83.07 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 92.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 83.07 } ], "minimum": 27.54232, "maximum": 496.76 } ] }, { "description": "MDI TREATMENT INITIAL", "code_information": [ { "code": "94640", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 106.6, "discounted_cash": 397.3983104, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 248.373944, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 15.90472, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 178.59 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 188.485416 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 15.90472, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 268.2438595, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 180.64, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 240.4259778, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 177.03, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 15.90472, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 15.90472, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 50.64, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 496.76, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 317.9186483, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 239.84, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 203.39 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 47.97 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 53.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 47.97 } ], "minimum": 15.90472, "maximum": 496.76 } ] }, { "description": "CPAP/BIPAP INIT & MGMT", "code_information": [ { "code": "94660", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 986.7, "discounted_cash": 397.3983104, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 248.373944, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 147.21564, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 186.09 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 188.485416 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 147.21564, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 268.2438595 }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.7, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 240.4259778, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 194.726, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 147.21564, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 147.21564, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.6825, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 497, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 317.9186483, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 239.84, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 203.39 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 444.015 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 493.35 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 444.015 } ], "minimum": 147.21564, "maximum": 497 } ] }, { "description": "INCENTIVE SPIROMETRY DEMO/EVAL", "code_information": [ { "code": "94664", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 188.5, "discounted_cash": 397.3983104, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 248.373944, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 28.1242, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 178.59 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 188.485416 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 28.1242, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 268.2438595, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 180.64, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 240.4259778, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 177.03, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 28.1242, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 28.1242, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 89.54, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 496.76, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 317.9186483, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 239.84, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 203.39 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 84.825 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 94.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 84.825 } ], "minimum": 28.1242, "maximum": 496.76 } ] }, { "description": "PULMONARY ASSESSMENT", "code_information": [ { "code": "94664", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 352.3, "discounted_cash": 397.3983104, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 248.373944, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 52.56316, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 178.59 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 188.485416 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 52.56316, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 268.2438595, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 180.64, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 240.4259778, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 177.03, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 52.56316, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 52.56316, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 167.34, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 496.76, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 317.9186483, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 239.84, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 203.39 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 158.535 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 176.15 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 158.535 } ], "minimum": 52.56316, "maximum": 496.76 } ] }, { "description": "HAND HELD NEBULIZERS DEMO EVAL", "code_information": [ { "code": "94664", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 434.2, "discounted_cash": 397.3983104, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 248.373944, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.78264, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 178.59 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 188.485416 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.78264, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 268.2438595, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 180.64, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 240.4259778, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 177.03, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.78264, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.78264, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 206.25, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 496.76, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 317.9186483, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 239.84, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 203.39 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 195.39 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 217.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 195.39 } ], "minimum": 64.78264, "maximum": 496.76 } ] }, { "description": "MDI DEMO AND/OR EVAL", "code_information": [ { "code": "94664", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 178.1, "discounted_cash": 397.3983104, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 248.373944, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 26.57252, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 178.59 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 188.485416 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 26.57252, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 268.2438595, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 180.64, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 240.4259778, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 177.03, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 26.57252, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 26.57252, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 84.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 496.76, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 317.9186483, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 239.84, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 198.6991552, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 203.39 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 80.145 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 89.05 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 80.145 } ], "minimum": 26.57252, "maximum": 496.76 } ] }, { "description": "PULSE OX SINGLE DETERM", "code_information": [ { "code": "94760", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 133.9, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 19.97788, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 19.97788, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 19.97788, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 19.97788, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 63.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 60.255 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 66.95 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 60.255 } ], "minimum": 0.01, "maximum": 66.95 } ] }, { "description": "PULSE OXIMETR MNTR/HR CONTINUOUS", "code_information": [ { "code": "94762", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.4, "discounted_cash": 233.5150272, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 145.946892, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 116.7575136, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.49128, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 134.31 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 141.75341 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 116.7575136, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.49128, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 157.6226434, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 138.963, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 141.2765915, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 136.18, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.49128, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.49128, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.12, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 382.15, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 116.7575136, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 186.8120218, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 140.93, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 116.7575136, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 156.46 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.53 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.7 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.53 } ], "minimum": 3.49128, "maximum": 382.15 } ] }, { "description": "Ndl emg cranial nrv musc uni", "code_information": [ { "code": "95867", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 118.3, "discounted_cash": 391.856192, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 244.91012, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 195.928096, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 17.65036, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 134.31 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 141.75341 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 195.928096, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 17.65036, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 264.5029296, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 276.573024, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 237.0729962, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 271.04, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 17.65036, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 17.65036, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 56.19, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 760.58, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 195.928096, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 313.4849536, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 236.49, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 195.928096, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 311.4 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 53.235 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 59.15 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 53.235 } ], "minimum": 17.65036, "maximum": 760.58 } ] }, { "description": "INTRA-OP MONITORING NATIONAL NEUROMONITO", "code_information": [ { "code": "95940", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 800, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 380, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 360 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 400 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 360 } ], "minimum": 0.01, "maximum": 400 } ] }, { "description": "INTRA-OP MONITORING ACCUNERVE", "code_information": [ { "code": "95940", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 800, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 380, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 360 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 400 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 360 } ], "minimum": 0.01, "maximum": 400 } ] }, { "description": "INTRA-OP MONITORING NEURO TECHNOLOGY", "code_information": [ { "code": "95940", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 800, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 380, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 360 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 400 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 360 } ], "minimum": 0.01, "maximum": 400 } ] }, { "description": "IMPULSE MONITORING", "code_information": [ { "code": "95940", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 800, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 380, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 360 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 400 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 360 } ], "minimum": 0.01, "maximum": 400 } ] }, { "description": "INTRA-OP MONITORING UNITED MEDICAL PC", "code_information": [ { "code": "95940", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 800, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 119.36, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 380, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 360 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 400 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 360 } ], "minimum": 0.01, "maximum": 400 } ] }, { "description": "PT THERAPEUTIC PROC 1+ AREA EA 15 MIN", "code_information": [ { "code": "97110", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 135.2, "discounted_cash": 56.6, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 35.375, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 28.3, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.21, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 30.18 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 30.563818 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 28.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.21, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 38.205 }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 28.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 34.243, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 27.734, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.21, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.21, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 64.22, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 91.85, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 28.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 45.28, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 43.582, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 28.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 29.43 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 60.84 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 67.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 60.84 } ], "minimum": 16.21, "maximum": 91.85 } ] }, { "description": "PT EVAL", "code_information": [ { "code": "97161", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 354.9, "discounted_cash": 190.38, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.9875, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 95.19, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 74.48, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 83.96 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 85.0418 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 95.19, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 74.48, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 128.5065 }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 95.19, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 115.1799, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 93.2862, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 74.48, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 74.48, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 168.5775, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 278.0525, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 95.19, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 152.304, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 146.5926, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 95.19, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 99 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 159.705 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 177.45 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 159.705 } ], "minimum": 74.48, "maximum": 278.0525 } ] }, { "description": "OT RE-EVAL", "code_information": [ { "code": "97168", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 187.2, "discounted_cash": 132.78, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 82.9875, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 66.39, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 47.58, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 60.85 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 61.62969 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 66.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 47.58, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 89.6265 }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 66.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 80.3319, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 65.0622, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 47.58, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 47.58, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 88.92, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 182.5725, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 66.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.224, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 102.2406, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 66.39, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 69.05 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 84.24 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 93.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 84.24 } ], "minimum": 47.58, "maximum": 182.5725 } ] }, { "description": "PT THERAPEUTIC ACTIVITY EA 15 MIN", "code_information": [ { "code": "97530", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 131.3, "discounted_cash": 67.86, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 42.4125, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 33.93, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 38.16 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 38.647912 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 33.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 45.8055 }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 33.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 41.0553, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 33.2514, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.76, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 62.3675, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 90.0625, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 33.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 54.288, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 52.2522, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 33.93, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 35.29 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 59.085 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 65.65 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 59.085 } ], "minimum": 8.76, "maximum": 90.0625 } ] }, { "description": "1st hosp ip/obs moderate 55", "code_information": [ { "code": "99222", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 93.6, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 145.16, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 133.75 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 141.159142 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 145.16, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 145.16, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 145.16, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 44.46, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 42.12 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 46.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 42.12 } ], "minimum": 42.12, "maximum": 145.16 } ] }, { "description": "Sbsq hosp ip/obs moderate 35", "code_information": [ { "code": "99232", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 41, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.03, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.03, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.03, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 64.03, "additional_payer_notes": "100% medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 19.48, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 18.45 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.45 } ], "minimum": 0.01, "maximum": 64.03 } ] }, { "description": "FLUCONAZOLE (DIFLUCAN) TAB 150 MG", "code_information": [ { "code": "00001-5018-24", "type": "NDC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 25.35, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 506.69528, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "other", "standard_charge_dollar": 405.356224, "additional_payer_notes": "not payable" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 12.04, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 11.4075 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.675 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.4075 } ], "minimum": 11.4075, "maximum": 506.69528 } ] }, { "description": "DEXMEDETOMIDINE IV 400MCG/100ML", "code_information": [ { "code": "00002-8215-01", "type": "NDC" } ], "drug_information": { "unit": 100, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 624, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 141.150828, "additional_payer_notes": "125% of Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "other", "standard_charge_dollar": 112.9206624, "additional_payer_notes": "not payable" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 280.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 312 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 280.8 } ], "minimum": 112.9206624, "maximum": 312 } ] }, { "description": "INSULIN REGULAR (HUMULIN-R) 3 ML", "code_information": [ { "code": "00002-8215-17", "type": "NDC" }, { "code": "J1815", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 29.9, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "other", "standard_charge_dollar": 112.9206624, "additional_payer_notes": "not payable" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.4385, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.56 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.56 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.4385, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.4385, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.4385, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 14.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 13.455 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.95 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.455 } ], "minimum": 0.56, "maximum": 112.9206624 } ] }, { "description": "TRAZODONE (DESYREL) TAB 50 MG", "code_information": [ { "code": "00003-0293-05", "type": "NDC" }, { "code": "J8499", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "MAG-HY/ALUM-HY/SIMETHICONE SUSP 12 OZ", "code_information": [ { "code": "00006-5423-12", "type": "NDC" }, { "code": "J8499", "type": "HCPCS" } ], "drug_information": { "unit": 2, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 15.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 7.41, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7.02 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.02 } ], "minimum": 7.02, "maximum": 7.8 } ] }, { "description": "HYDROCORTISONE SOD SUCC INJ 100 MG", "code_information": [ { "code": "00009-0825-01", "type": "NDC" }, { "code": "J1720", "type": "HCPCS" } ], "drug_information": { "unit": 100, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 142.29, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.36335, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 19.44 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 19.44 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.36335, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.36335, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.36335, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 67.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 64.0305 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 71.145 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 64.0305 } ], "minimum": 16.36335, "maximum": 71.145 } ] }, { "description": "CEFAZOLIN INJ 2GM", "code_information": [ { "code": "00009-2250-01", "type": "NDC" }, { "code": "J0690", "type": "HCPCS" } ], "drug_information": { "unit": 2, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 38.06, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.3769, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.8 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.8 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.3769, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.3769, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.3769, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 18.08, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 17.127 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.03 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.127 } ], "minimum": 0.8, "maximum": 19.03 } ] }, { "description": "HEPARIN INF : 1,000 UNITS/NS 500 ML", "code_information": [ { "code": "00009-3475-01", "type": "NDC" }, { "code": "J1644", "type": "HCPCS" } ], "drug_information": { "unit": 500, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 34.71, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.99165, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.31 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.31 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.99165, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.99165, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.99165, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.49, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.6195 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.355 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.6195 } ], "minimum": 0.31, "maximum": 17.355 } ] }, { "description": "OFLOXACIN OPH SOLN 0.3% : 5 ML", "code_information": [ { "code": "00023-1145-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 457.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 217.21, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 205.776 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 228.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 205.776 } ], "minimum": 205.776, "maximum": 228.64 } ] }, { "description": "CELECOXIB (CELEBREX) CAP 100 MG", "code_information": [ { "code": "00025-1520-34", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 29.77, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 14.14, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 13.3965 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.885 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.3965 } ], "minimum": 0.01, "maximum": 14.885 } ] }, { "description": "MORPHINE SO4 TAB IR 15 MG", "code_information": [ { "code": "00054-0235-24", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "WARFARIN (COUMADIN) TAB 2.5 MG", "code_information": [ { "code": "00056-0173-75", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "ASCORBIC ACID TAB 500 MG", "code_information": [ { "code": "00056-0176-75", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "VERAPAMIL (CALAN) INJ : 5 MG/2 ML", "code_information": [ { "code": "00065-0006-03", "type": "NDC" } ], "drug_information": { "unit": 2, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 81.25, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 38.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 36.5625 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 40.625 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 36.5625 } ], "minimum": 36.5625, "maximum": 40.625 } ] }, { "description": "Bupivacaine Liposome 133mg/10ml", "code_information": [ { "code": "00065-0023-15", "type": "NDC" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 1882.1, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 894, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 846.945 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 941.05 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 846.945 } ], "minimum": 846.945, "maximum": 941.05 } ] }, { "description": "TIZANIDINE (ZANAFLEX) TAB 4 MG", "code_information": [ { "code": "00065-0741-12", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "TEMAZEPAM (RESTORIL) CAP 15 MG", "code_information": [ { "code": "00065-0741-12", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "BALANCED SALT SOLN : 15 ML", "code_information": [ { "code": "00065-0795-15", "type": "NDC" } ], "drug_information": { "unit": 15, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 98.67, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 46.87, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 44.4015 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 49.335 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 44.4015 } ], "minimum": 44.4015, "maximum": 49.335 } ] }, { "description": "PREDNISONE TAB 5 MG", "code_information": [ { "code": "00071-1013-41", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "BETAMETHASONE ACET/NA PHOS INJ : 5 ML", "code_information": [ { "code": "00085-0566-05", "type": "NDC" }, { "code": "J0702", "type": "HCPCS" } ], "drug_information": { "unit": 5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 429.26, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 7.05 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 7.05 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 203.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 193.167 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 214.63 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 193.167 } ], "minimum": 7.05, "maximum": 214.63 } ] }, { "description": "NITROFURANTOIN MACRO CAP 50 MG", "code_information": [ { "code": "00093-2130-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 28.73, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.65, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 12.9285 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.365 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.9285 } ], "minimum": 12.9285, "maximum": 14.365 } ] }, { "description": "LISINOPRIL (PRINIVIL) TAB 5 MG", "code_information": [ { "code": "00093-3147-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "BUMETANIDE (BUMEX) TAB 1 MG", "code_information": [ { "code": "00093-4233-01", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "BUDESONIDE RESPULE 0.5 MG/2 ML", "code_information": [ { "code": "00093-6816-73", "type": "NDC" }, { "code": "J7626", "type": "HCPCS" } ], "drug_information": { "unit": 2, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 80, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1.27 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1.27 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 38, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 36 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 40 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 36 } ], "minimum": 1.27, "maximum": 40 } ] }, { "description": "ACETAMINOPHEN/COD LIQ 120-12MG/5ML", "code_information": [ { "code": "00121-0504-05", "type": "NDC" }, { "code": "J8499", "type": "HCPCS" } ], "drug_information": { "unit": 5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 63.26, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 30.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 28.467 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 31.63 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 28.467 } ], "minimum": 28.467, "maximum": 31.63 } ] }, { "description": "LABETALOL INJ 20 MG/4 ML SYRINGE", "code_information": [ { "code": "00121-1761-30", "type": "NDC" } ], "drug_information": { "unit": 4, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 70.85, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 33.65, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 31.8825 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 35.425 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 31.8825 } ], "minimum": 31.8825, "maximum": 35.425 } ] }, { "description": "LIDOCAINE 1% 50 ML VIAL", "code_information": [ { "code": "00143-9622-01", "type": "NDC" } ], "drug_information": { "unit": 50, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 44.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.14, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 20.025 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.025 } ], "minimum": 20.025, "maximum": 22.25 } ] }, { "description": "NYSTATIN/TRIAMCINOLONE CR 100 MU/0.1%", "code_information": [ { "code": "00168-0081-15", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 15, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 163.41, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 77.62, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 73.5345 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 81.705 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 73.5345 } ], "minimum": 73.5345, "maximum": 81.705 } ] }, { "description": "BACLOFEN (LIORESAL) TAB 10 MG", "code_information": [ { "code": "00172-4096-60", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "NICOTINE (NICODERM CQ) PATCH 21 MG", "code_information": [ { "code": "00172-5412-11", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 14.3, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.79, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.435 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.15 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.435 } ], "minimum": 6.435, "maximum": 7.15 } ] }, { "description": "ALBUTEROL INHALER 60 INHALATIONS", "code_information": [ { "code": "00173-0682-21", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 177.25, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 84.19, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 79.7625 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 88.625 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 79.7625 } ], "minimum": 0.01, "maximum": 88.625 } ] }, { "description": "SODIUM PHOSPHATES MB/DB ENEMA 133 ML", "code_information": [ { "code": "00223-1721-01", "type": "NDC" } ], "drug_information": { "unit": 133, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.83, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.24, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.0735 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.415 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.0735 } ], "minimum": 3.0735, "maximum": 3.415 } ] }, { "description": "SOD CHLORIDE INJ 0.9% : 50 ML", "code_information": [ { "code": "00245-0012-01", "type": "NDC" } ], "drug_information": { "unit": 50, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 58.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 27.79, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 26.325 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.325 } ], "minimum": 26.325, "maximum": 29.25 } ] }, { "description": "SOD CHLORIDE INJ 0.9% 100 ML PLUS", "code_information": [ { "code": "00264-1800-32", "type": "NDC" } ], "drug_information": { "unit": 100, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 52, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 23.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 26 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.4 } ], "minimum": 23.4, "maximum": 26 } ] }, { "description": "LACTATED RINGER'S INJ : 1000 ML", "code_information": [ { "code": "00264-7750-00", "type": "NDC" }, { "code": "J1720", "type": "HCPCS" } ], "drug_information": { "unit": 1000, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 58.5, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7275, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 19.44 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 19.44 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7275, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7275, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7275, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 27.79, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 26.325 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.325 } ], "minimum": 6.7275, "maximum": 29.25 } ] }, { "description": "SOD CHLORIDE INJ 0.9% : 100 ML", "code_information": [ { "code": "00264-7800-20", "type": "NDC" } ], "drug_information": { "unit": 100, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 58.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 27.79, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 26.325 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.325 } ], "minimum": 26.325, "maximum": 29.25 } ] }, { "description": "SIMETHICONE DROPS 40 MG/0.6 ML", "code_information": [ { "code": "00264-7802-00", "type": "NDC" } ], "drug_information": { "unit": 40, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 17.03, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 8.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7.6635 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.515 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.6635 } ], "minimum": 7.6635, "maximum": 8.515 } ] }, { "description": "LIDOCAINE 4% 200 MG/5 ML AMP MPF", "code_information": [ { "code": "00264-9872-10", "type": "NDC" } ], "drug_information": { "unit": 5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 29.58, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 14.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 13.311 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.79 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.311 } ], "minimum": 13.311, "maximum": 14.79 } ] }, { "description": "NITROGLYCERIN OINT 2% 1 GRAM PKT", "code_information": [ { "code": "00281-0326-30", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.69, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.35, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.8605 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.845 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.8605 } ], "minimum": 8.8605, "maximum": 9.845 } ] }, { "description": "SODIUM BICARBONATE 8.4% 50 ML VIAL", "code_information": [ { "code": "00338-0553-18", "type": "NDC" } ], "drug_information": { "unit": 50, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 75.73, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 35.97, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 34.0785 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 37.865 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 34.0785 } ], "minimum": 34.0785, "maximum": 37.865 } ] }, { "description": "NITROGLYCERIN INJ 50 MG/D5W 250 ML", "code_information": [ { "code": "00338-1049-02", "type": "NDC" } ], "drug_information": { "unit": 50, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 175.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 83.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 79.11 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 87.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 79.11 } ], "minimum": 79.11, "maximum": 87.9 } ] }, { "description": "PROPOFOL (DIPRIVAN) INJ : 200 MG/20 ML", "code_information": [ { "code": "00378-0183-01", "type": "NDC" } ], "drug_information": { "unit": 200, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 8.775, "maximum": 9.75 } ] }, { "description": "LEVOTHYROXINE TAB 25 MCG", "code_information": [ { "code": "00378-1800-77", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "TRYPAN BLUE OPHTH : 0.06% SYRINGE", "code_information": [ { "code": "00378-5814-77", "type": "NDC" } ], "drug_information": { "unit": 0.5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 496, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 235.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 223.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 248 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 223.2 } ], "minimum": 223.2, "maximum": 248 } ] }, { "description": "LEVALBUTEROL INH SOLN 1.25 MG/0.5 ML", "code_information": [ { "code": "00378-6993-31", "type": "NDC" }, { "code": "J7614", "type": "HCPCS" } ], "drug_information": { "unit": 0.5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 43.55, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.06 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.06 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 20.69, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 19.5975 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.775 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.5975 } ], "minimum": 0.06, "maximum": 21.775 } ] }, { "description": "HYDROCODONE/ACET (NORCO) TAB 5/325 MG", "code_information": [ { "code": "00406-0123-62", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "MORPHINE SO4 TAB ER 15 MG", "code_information": [ { "code": "00406-8315-62", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 12.35, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.87, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.5575 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.175 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.5575 } ], "minimum": 5.5575, "maximum": 6.175 } ] }, { "description": "IOHEXOL (OMNIPAQUE) 240MG/ML, 2 ML", "code_information": [ { "code": "00407-1413-50", "type": "NDC" }, { "code": "Q9967", "type": "HCPCS" } ], "drug_information": { "unit": 2, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 64.35, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.14 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 30.57, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 28.9575 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 32.175 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 28.9575 } ], "minimum": 0.14, "maximum": 32.175 } ] }, { "description": "BUPIVACAINE MPF INJ : 0.5% 30 ML VIAL", "code_information": [ { "code": "00409-1162-02", "type": "NDC" }, { "code": "J0665", "type": "HCPCS" } ], "drug_information": { "unit": 30, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.02 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.02 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 0.02, "maximum": 9.75 } ] }, { "description": "DIAZEPAM (VALIUM) SYRINGE 10 MG/2 ML", "code_information": [ { "code": "00409-1273-03", "type": "NDC" }, { "code": "J3360", "type": "HCPCS" } ], "drug_information": { "unit": 2, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 192, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 22.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 8.23 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 8.23 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 22.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 22.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 22.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 91.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 86.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 96 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 86.4 } ], "minimum": 8.23, "maximum": 96 } ] }, { "description": "LIDOCAINE 2% INJ 100MG/5ML SYR", "code_information": [ { "code": "00409-1323-05", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 65.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 31.11, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 29.475 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 32.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.475 } ], "minimum": 29.475, "maximum": 32.75 } ] }, { "description": "ATROPINE INJ 0.1 MG/ML 10 ML SYRINGE", "code_information": [ { "code": "00409-1630-10", "type": "NDC" }, { "code": "J0461", "type": "HCPCS" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 72.15, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.29725, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.1 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.1 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.29725, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.29725, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.29725, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 34.27, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 32.4675 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 36.075 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 32.4675 } ], "minimum": 0.1, "maximum": 36.075 } ] }, { "description": "BUPIVACAINE/DEX SPINAL INJ : 0.75% 2 ML", "code_information": [ { "code": "00409-1761-02", "type": "NDC" }, { "code": "J0665", "type": "HCPCS" } ], "drug_information": { "unit": 2, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 35.1, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.02 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.02 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.67, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.795 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.55 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.795 } ], "minimum": 0.02, "maximum": 17.55 } ] }, { "description": "MORPHINE SULFATE IV SOLUTION 2MG/1ML", "code_information": [ { "code": "00409-1890-03", "type": "NDC" }, { "code": "J2270", "type": "HCPCS" } ], "drug_information": { "unit": 2, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 22.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4.75 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4.75 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 10.69, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.125 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.125 } ], "minimum": 4.75, "maximum": 11.25 } ] }, { "description": "MORPHINE SO4 PCA : 1 MG/ML 100 ML BAG", "code_information": [ { "code": "00409-2029-02", "type": "NDC" } ], "drug_information": { "unit": 1, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 253.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 120.41, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 114.075 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 126.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 114.075 } ], "minimum": 114.075, "maximum": 126.75 } ] }, { "description": "LISINOPRIL (PRINIVIL) TAB 40 MG", "code_information": [ { "code": "00409-2720-02", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "LIDOCAINE/EPI 1%/0.001% 20 ML VIAL", "code_information": [ { "code": "00409-3178-01", "type": "NDC" }, { "code": "J2003", "type": "HCPCS" } ], "drug_information": { "unit": 20, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 38.3, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 18.19, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 17.235 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.15 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.235 } ], "minimum": 0.01, "maximum": 19.15 } ] }, { "description": "HYDROMORPHONE (DILAUDID) INJ 2 MG", "code_information": [ { "code": "00409-3365-11", "type": "NDC" }, { "code": "J1171", "type": "HCPCS" } ], "drug_information": { "unit": 2, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.4, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.15 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.11 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.12, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.53 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.7 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.53 } ], "minimum": 0.11, "maximum": 11.7 } ] }, { "description": "LIDOCAINE 1% 20 ML VIAL", "code_information": [ { "code": "00409-4276-01", "type": "NDC" }, { "code": "J2003", "type": "HCPCS" } ], "drug_information": { "unit": 20, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 48.62, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 23.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 21.879 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 24.31 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.879 } ], "minimum": 0.01, "maximum": 24.31 } ] }, { "description": "BUPIVACAINE MPF INJ : 0.5% 10 ML", "code_information": [ { "code": "00409-4276-01", "type": "NDC" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.575 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.575 } ], "minimum": 10.575, "maximum": 11.75 } ] }, { "description": "LIDOCAINE 1% 30 ML VIAL MPF", "code_information": [ { "code": "00409-4279-02", "type": "NDC" }, { "code": "J2003", "type": "HCPCS" } ], "drug_information": { "unit": 30, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 79.95, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 37.98, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 35.9775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 39.975 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 35.9775 } ], "minimum": 35.9775, "maximum": 39.975 } ] }, { "description": "WARFARIN (COUMADIN) TAB 7.5 MG", "code_information": [ { "code": "00409-4283-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "LIDOCAINE 4% KIT", "code_information": [ { "code": "00409-4698-01", "type": "NDC" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 141.38, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 67.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 63.621 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 70.69 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 63.621 } ], "minimum": 63.621, "maximum": 70.69 } ] }, { "description": "CIPROFLOXACIN (CIPRO) IVPB 400 MG", "code_information": [ { "code": "00409-4777-02", "type": "NDC" }, { "code": "J0744", "type": "HCPCS" } ], "drug_information": { "unit": 400, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 58.5, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7275, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2.01 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7275, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7275, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7275, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 27.79, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 26.325 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.325 } ], "minimum": 2.01, "maximum": 29.25 } ] }, { "description": "SPIRONOLACTONE (ALDACTONE) TAB 25 MG", "code_information": [ { "code": "00409-4887-10", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "METHOCARBAMOL (ROBAXIN) INJ 1 GM/10 ML", "code_information": [ { "code": "00409-4888-10", "type": "NDC" } ], "drug_information": { "unit": 1, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 78, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 37.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 35.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 39 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 35.1 } ], "minimum": 35.1, "maximum": 39 } ] }, { "description": "BUPIVACAINE MPF INJ : 0.25% 10 ML", "code_information": [ { "code": "00409-6531-02", "type": "NDC" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 47.13, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 22.39, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 21.2085 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.565 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.2085 } ], "minimum": 21.2085, "maximum": 23.565 } ] }, { "description": "SODIUM BICARBONATE TAB 325MG", "code_information": [ { "code": "00409-6625-02", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "POTASSIUM CL INJ 20 MEQ/100 ML H20 INJ", "code_information": [ { "code": "00409-7075-26", "type": "NDC" }, { "code": "J3480", "type": "HCPCS" } ], "drug_information": { "unit": 100, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 20.8, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.12 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.12 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.88, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9.36 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.36 } ], "minimum": 0.12, "maximum": 10.4 } ] }, { "description": "EPINEPHRINE SU/F PF : 1:1000 1 ML AMP", "code_information": [ { "code": "00409-7241-01", "type": "NDC" }, { "code": "J0165", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 113.75, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.51 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 54.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 51.1875 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 56.875 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 51.1875 } ], "minimum": 0.51, "maximum": 56.875 } ] }, { "description": "DEXTROSE 50% INJ 50 ML SYRINGE", "code_information": [ { "code": "00409-7517-16", "type": "NDC" } ], "drug_information": { "unit": 50, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 143.75, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 68.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 64.6875 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 71.875 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 64.6875 } ], "minimum": 64.6875, "maximum": 71.875 } ] }, { "description": "ACETAMINOPHEN INJ 1000 MG/100 ML", "code_information": [ { "code": "00409-7620-59", "type": "NDC" }, { "code": "J0131", "type": "HCPCS" } ], "drug_information": { "unit": 100, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 93.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.06 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.08 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 44.46, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 42.12 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 46.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 42.12 } ], "minimum": 0.06, "maximum": 46.8 } ] }, { "description": "BUPIVACAINE/EPI-MPF : 0.25% 10 ML", "code_information": [ { "code": "00409-9045-02", "type": "NDC" }, { "code": "J0665", "type": "HCPCS" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 36.14, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.02 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.02 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.17, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.263 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.07 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.263 } ], "minimum": 0.02, "maximum": 18.07 } ] }, { "description": "FENTANYL INJ 250 MCG/5 ML", "code_information": [ { "code": "00409-9093-35", "type": "NDC" }, { "code": "J3010", "type": "HCPCS" } ], "drug_information": { "unit": 5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.94 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.94 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 0.94, "maximum": 9.75 } ] }, { "description": "NEBIVOLOL (BYSTOLIC) TAB 5 MG", "code_information": [ { "code": "00456-1405-63", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 24.7, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.73, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 11.115 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.35 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.115 } ], "minimum": 11.115, "maximum": 12.35 } ] }, { "description": "HEPARIN INJ : 1,000 UNITS/ML 30 ML VIAL", "code_information": [ { "code": "00472-1105-56", "type": "NDC" } ], "drug_information": { "unit": 30, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 55.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.36, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 24.975 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 27.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 24.975 } ], "minimum": 24.975, "maximum": 27.75 } ] }, { "description": "BUTALBITAL/APAP/CAFF (FIORICET) TAB", "code_information": [ { "code": "00527-1695-01", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.13, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.86, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.6585 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.065 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.6585 } ], "minimum": 0.01, "maximum": 4.065 } ] }, { "description": "MECLIZINE HCL (ANTIVERT) TAB 12.5 MG", "code_information": [ { "code": "00536-1178-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "SIMETHICONE (MYLICON) TAB 80 MG CHEW", "code_information": [ { "code": "00536-2220-75", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "ESTRADIOL VAG CR 0.01% : 42.5 GRAM", "code_information": [ { "code": "00536-2425-58", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 42.5, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 2016.36, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 957.77, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 907.362 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1008.18 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 907.362 } ], "minimum": 907.362, "maximum": 1008.18 } ] }, { "description": "NICOTINE (NICODERM CQ) PATCH 14 MG", "code_information": [ { "code": "00536-5895-88", "type": "NDC" }, { "code": "J2305", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 15.54, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1.42 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1.42 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 7.38, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.993 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.77 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.993 } ], "minimum": 1.42, "maximum": 7.77 } ] }, { "description": "CYANOCOBALAMIN TAB 1000 MCG", "code_information": [ { "code": "00536-6556-01", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "LIDOCAINE 2% URO-JET 10 ML", "code_information": [ { "code": "00548-3013-00", "type": "NDC" }, { "code": "J3490", "type": "HCPCS" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 51.35, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.90525, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.90525, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.90525, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.90525, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.39, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 23.1075 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.675 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.1075 } ], "minimum": 5.90525, "maximum": 25.675 } ] }, { "description": "MIDAZOLAM HCL (VERSED) SYRP : 10 MG/5 ML", "code_information": [ { "code": "00574-0150-04", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 10, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 47.78, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 22.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 21.501 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.89 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.501 } ], "minimum": 21.501, "maximum": 23.89 } ] }, { "description": "ESTRADIOL (ESTRACE) TAB 0.5 MG", "code_information": [ { "code": "00591-0528-01", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "SILVER NITRATE STICK", "code_information": [ { "code": "00591-0810-83", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 13, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.18, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.85 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.85 } ], "minimum": 5.85, "maximum": 6.5 } ] }, { "description": "CLINDAMYCIN (CLEOCIN) CAP 150 MG", "code_information": [ { "code": "00591-5708-01", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.8, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.71, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.51 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.51 } ], "minimum": 0.01, "maximum": 3.9 } ] }, { "description": "ASPIRIN TAB 81 MG CHEWABLE", "code_information": [ { "code": "00603-0026-22", "type": "NDC" }, { "code": "J8499", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "PROMETHAZINE (PHENERGAN) TAB 25 MG", "code_information": [ { "code": "00641-0928-25", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "FAMOTIDINE (PEPCID) INJ 20 MG/2 ML", "code_information": [ { "code": "00641-6022-25", "type": "NDC" }, { "code": "J3490", "type": "HCPCS" } ], "drug_information": { "unit": 2, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 2.2425, "maximum": 9.75 } ] }, { "description": "FENTANYL INJ 100 MCG/2 ML", "code_information": [ { "code": "00641-6027-25", "type": "NDC" }, { "code": "J3010", "type": "HCPCS" } ], "drug_information": { "unit": 2, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.92 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.94 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 0.92, "maximum": 9.75 } ] }, { "description": "MIDAZOLAM (VERSED) INJ 2 MG/2 ML VIAL", "code_information": [ { "code": "00641-6057-01", "type": "NDC" }, { "code": "J2250", "type": "HCPCS" } ], "drug_information": { "unit": 2, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.19 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 0.14, "maximum": 9.75 } ] }, { "description": "OXYCODONE/ACET TAB 7.5 MG/325 MG", "code_information": [ { "code": "00641-6103-25", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 20.63, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9.2835 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.315 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.2835 } ], "minimum": 9.2835, "maximum": 10.315 } ] }, { "description": "PHENOL/METHOL (CEPACOL) LOZ", "code_information": [ { "code": "00641-6142-25", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "PROMETHAZINE (PHENERGAN) INJ 25 MG/ML", "code_information": [ { "code": "00703-2859-03", "type": "NDC" } ], "drug_information": { "unit": 25, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 14.43, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.85, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.4935 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.215 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.4935 } ], "minimum": 6.4935, "maximum": 7.215 } ] }, { "description": "ENOXAPARIN (LOVENOX) INJ 40 MG", "code_information": [ { "code": "00703-8540-21", "type": "NDC" }, { "code": "J1650", "type": "HCPCS" } ], "drug_information": { "unit": 40, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 21.92, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.5208, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.73 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.73 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.5208, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.5208, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.5208, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 10.41, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9.864 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.96 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.864 } ], "minimum": 0.73, "maximum": 10.96 } ] }, { "description": "CEFDINIR (OMNICEF) CAP 300 MG", "code_information": [ { "code": "00781-2176-60", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 33.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 15.77, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 14.94 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.94 } ], "minimum": 14.94, "maximum": 16.6 } ] }, { "description": "STERILE WATER 10 ML VIAL", "code_information": [ { "code": "00781-3009-95", "type": "NDC" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 8.775, "maximum": 9.75 } ] }, { "description": "INSULIN LISPRO (HUMALOG) INJ 3 ML", "code_information": [ { "code": "00781-3289-09", "type": "NDC" } ], "drug_information": { "unit": 3, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 108.55, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 51.56, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 48.8475 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 54.275 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 48.8475 } ], "minimum": 48.8475, "maximum": 54.275 } ] }, { "description": "ALBUTEROL INH SOLN 0.042% 1.25 MG/3 ML", "code_information": [ { "code": "00904-1988-61", "type": "NDC" } ], "drug_information": { "unit": 3, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.38, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.41, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.121 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.121 } ], "minimum": 5.121, "maximum": 5.69 } ] }, { "description": "FERROUS GLUCONATE (FERGON) TAB 324 MG", "code_information": [ { "code": "00904-2137-61", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "OXYBUTYNIN CL (DITROPAN) TAB 5 MG", "code_information": [ { "code": "00904-2821-61", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "ATENOLOL (TENORMIN) TAB 25 MG", "code_information": [ { "code": "00904-5392-61", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "OXYMETAZOLINE (AFRIN) NAS SPY 0.05% 30ml", "code_information": [ { "code": "00904-5711-35", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 26, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 12.35, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 11.7 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 13 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.7 } ], "minimum": 11.7, "maximum": 13 } ] }, { "description": "LORATIDINE (CLARITIN) TAB 10 MG", "code_information": [ { "code": "00904-5728-87", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "METFORMIN XR (GLUCOPHAGE) TAB 500 MG", "code_information": [ { "code": "00904-5794-61", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "FUROSEMIDE (LASIX) TAB 40 MG", "code_information": [ { "code": "00904-5797-61", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "OXYCODONE CR (OXYCONTIN) TAB 20 MG", "code_information": [ { "code": "00904-5824-61", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 84.52, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 40.15, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 38.034 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 42.26 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 38.034 } ], "minimum": 38.034, "maximum": 42.26 } ] }, { "description": "CLINDAMYCIN IVPB 600 MG PREMIXED", "code_information": [ { "code": "00904-5860-61", "type": "NDC" } ], "drug_information": { "unit": 600, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 96.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 45.84, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 43.425 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 48.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 43.425 } ], "minimum": 43.425, "maximum": 48.25 } ] }, { "description": "DIGOXIN (LANOXIN) TAB 125 MCG", "code_information": [ { "code": "00904-5921-61", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.92, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.19, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.914 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.46 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.914 } ], "minimum": 0.01, "maximum": 5.46 } ] }, { "description": "LORAZEPAM (ATIVAN) TAB 0.5 MG", "code_information": [ { "code": "00904-6007-60", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "ATORVASTATIN (LIPITOR) TAB 10 MG", "code_information": [ { "code": "00904-6290-61", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "METOPROLOL TART (LOPRESSOR) TAB 25 MG", "code_information": [ { "code": "00904-6340-61", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "METOPROLOL TART (LOPRESSOR) TAB 50 MG", "code_information": [ { "code": "00904-6341-61", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "ZOLPIDEM (AMBIEN) TAB 5 MG", "code_information": [ { "code": "00904-6371-61", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "CIPROFLOXACIN (CIPRO) TAB 500 MG", "code_information": [ { "code": "00904-6378-61", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "SUMATRIPTAN (IMITREX) TAB 50 MG", "code_information": [ { "code": "00904-6401-61", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 163.41, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 77.62, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 73.5345 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 81.705 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 73.5345 } ], "minimum": 73.5345, "maximum": 81.705 } ] }, { "description": "HYDRALAZINE (APRESOLINE) TAB 25 MG", "code_information": [ { "code": "00904-6441-61", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "MINERAL OIL/WHITE PETROL OPTH OINT", "code_information": [ { "code": "00904-6488-38", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 3.5, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 76.18, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 36.19, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 34.281 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 38.09 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 34.281 } ], "minimum": 34.281, "maximum": 38.09 } ] }, { "description": "SCOPOLAMINE PATCH 1.5 MG", "code_information": [ { "code": "00904-6522-61", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 149.25, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.89, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 67.1625 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 74.625 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 67.1625 } ], "minimum": 67.1625, "maximum": 74.625 } ] }, { "description": "AMIODARONE TAB 200 MG", "code_information": [ { "code": "00904-6556-61", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "ALLOPURINOL (ZYLOPRIM) TAB 100 MG", "code_information": [ { "code": "00904-6571-61", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 2.57, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.22, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.1565 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.285 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.1565 } ], "minimum": 0.01, "maximum": 1.285 } ] }, { "description": "GABAPENTIN (NEURONTIN) CAP 300 MG", "code_information": [ { "code": "00904-6666-61", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.010246 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "METFORMIN (GLUCOPHAGE) TAB 500 MG", "code_information": [ { "code": "00904-6689-61", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "ASPIRIN TAB 325 MG", "code_information": [ { "code": "00904-6744-60", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "LISINOPRIL (PRINIVIL) TAB 10 MG", "code_information": [ { "code": "00904-6798-61", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "MONTELUKAST (SINGULAIR) TAB 10 MG", "code_information": [ { "code": "00904-6800-61", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "DOCUSATE SOD (COLACE) 100 MG", "code_information": [ { "code": "00904-6998-60", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "PREGABALIN (LYRICA) CAP 50 MG", "code_information": [ { "code": "00904-7000-61", "type": "NDC" }, { "code": "J0780", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3.14 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 2.2425, "maximum": 9.75 } ] }, { "description": "MORPHINE SO4 INJ 4 MG/ML", "code_information": [ { "code": "00904-7049-61", "type": "NDC" } ], "drug_information": { "unit": 4, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.48, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.25, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.766 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.74 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.766 } ], "minimum": 8.766, "maximum": 9.74 } ] }, { "description": "OXYCODONE IR (ROXICODONE) TAB 5 MG", "code_information": [ { "code": "00904-7094-61", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "ACETAMINOPHEN (TYLENOL) TAB 500 MG", "code_information": [ { "code": "00904-7095-61", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "Eye Bag", "code_information": [ { "code": "00904-7435-35", "type": "NDC" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 92.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 87.84 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 97.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 87.84 } ], "minimum": 87.84, "maximum": 97.6 } ] }, { "description": "HYDROCORTISONE CREAM 1% 30 GM", "code_information": [ { "code": "00904-7623-31", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 30, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 25.94, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 12.32, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 11.673 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.97 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.673 } ], "minimum": 11.673, "maximum": 12.97 } ] }, { "description": "CLOTRIMAZOLE TOP CRM 1%", "code_information": [ { "code": "00904-7822-31", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 30, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 55.9, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 25.155 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 27.95 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.155 } ], "minimum": 0.01, "maximum": 27.95 } ] }, { "description": "IBUPROFEN (MOTRIN) TAB 200 MG", "code_information": [ { "code": "00904-7912-51", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "BISACODYL TAB 5 MG", "code_information": [ { "code": "00904-7927-61", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "FLUMAZENIL (ROMAZECON) INJ 0.5 MG/5 ML", "code_information": [ { "code": "01103-0781-30", "type": "NDC" }, { "code": "J3490", "type": "HCPCS" } ], "drug_information": { "unit": 5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 52.98, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.0927, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.0927, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.0927, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.0927, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 25.17, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 23.841 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.49 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.841 } ], "minimum": 6.0927, "maximum": 26.49 } ] }, { "description": "ALBUTEROL INH SOLN 0.083% 2.5 MG/3 ML", "code_information": [ { "code": "03050-0914-10", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 13, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.18, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.85 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.85 } ], "minimum": 0.01, "maximum": 6.5 } ] }, { "description": "DEXAMETHASONE (DECADRON) TAB 4 MG", "code_information": [ { "code": "05910-7940-01", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "CLINDAMYCIN IVPB 900 MG PREMIXED", "code_information": [ { "code": "07813--290-91", "type": "NDC" }, { "code": "J3490", "type": "HCPCS" } ], "drug_information": { "unit": 900, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 117.75, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.54125, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.54125, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.54125, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.54125, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 55.93, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 52.9875 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 58.875 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 52.9875 } ], "minimum": 13.54125, "maximum": 58.875 } ] }, { "description": "OXYCODONE/ACET TAB 10 MG/325 MG", "code_information": [ { "code": "09046-9666-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.25, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.04, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.4625 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.625 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.4625 } ], "minimum": 10.4625, "maximum": 11.625 } ] }, { "description": "MOXIFLOXACIN OPH SOLN : 0.5% 3 ML", "code_information": [ { "code": "10006-0700-21", "type": "NDC" } ], "drug_information": { "unit": 3, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 1087.78, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 489.501 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 543.89 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 489.501 } ], "minimum": 489.501, "maximum": 543.89 } ] }, { "description": "GLYCOPYRROLATE INJ : 1 MG/5 ML MDV", "code_information": [ { "code": "10019-0016-54", "type": "NDC" }, { "code": "J1596", "type": "HCPCS" } ], "drug_information": { "unit": 5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 291, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 33.465, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.5 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.49 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 33.465, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 33.465, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 33.465, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 138.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1.43, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 130.95 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 145.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 130.95 } ], "minimum": 0.49, "maximum": 145.5 } ] }, { "description": "MEPERIDINE (DEMEROL) INJ 25 MG", "code_information": [ { "code": "10019-0159-01", "type": "NDC" }, { "code": "J2175", "type": "HCPCS" } ], "drug_information": { "unit": 25, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 7.43 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 7.43 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 2.2425, "maximum": 9.75 } ] }, { "description": "PIOGLITAZONE HCL (ACTOS) TAB 15 MG", "code_information": [ { "code": "11523-7268-08", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 45.53, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.63, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 20.4885 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.765 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.4885 } ], "minimum": 20.4885, "maximum": 22.765 } ] }, { "description": "NALOXEGOL (MOVANTIK) TAB 25 MG", "code_information": [ { "code": "12843-0551-04", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 113.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 53.91, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 51.075 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 56.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 51.075 } ], "minimum": 51.075, "maximum": 56.75 } ] }, { "description": "SENNOSIDES (SENNA-LAX) TAB 8.6 MG", "code_information": [ { "code": "12870-0001-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "PREGABALIN (LYRICA) CAP 75 MG", "code_information": [ { "code": "14789-0700-02", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 8.775, "maximum": 9.75 } ] }, { "description": "ALBUTEROL/IPATROPIUM INH SOLN 3 ML", "code_information": [ { "code": "16252-0547-33", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 3, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 13, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.18, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.85 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.85 } ], "minimum": 0.01, "maximum": 6.5 } ] }, { "description": "PHYTONADIONE (VIT K) INJ 10 MG/ML", "code_information": [ { "code": "16729-0020-10", "type": "NDC" } ], "drug_information": { "unit": 10, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 333.58, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 158.45, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 150.111 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 166.79 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 150.111 } ], "minimum": 150.111, "maximum": 166.79 } ] }, { "description": "CLOPIDOGREL (PLAVIX) TAB 75 MG", "code_information": [ { "code": "16729-0218-10", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 44.28, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 19.926 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.14 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.926 } ], "minimum": 0.01, "maximum": 22.14 } ] }, { "description": "ERYTHROMYCIN OPH OINT 0.05%", "code_information": [ { "code": "17478-0070-35", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 3.5, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 123.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 58.66, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 55.575 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 61.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 55.575 } ], "minimum": 0.01, "maximum": 61.75 } ] }, { "description": "PHENYLEPHRINE INJ 10 MG/ML VIAL", "code_information": [ { "code": "17478-0205-10", "type": "NDC" } ], "drug_information": { "unit": 10, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 8.775, "maximum": 9.75 } ] }, { "description": "LIDOCAINE 2% (GLYDO) URO-JECT 6 ML", "code_information": [ { "code": "17478-0504-01", "type": "NDC" } ], "drug_information": { "unit": 6, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 46.41, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 22.04, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 20.8845 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.205 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.8845 } ], "minimum": 20.8845, "maximum": 23.205 } ] }, { "description": "GENTAMICIN IVPB 80 MG/NS 50 ML", "code_information": [ { "code": "17478-0713-10", "type": "NDC" } ], "drug_information": { "unit": 50, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 29.25, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.89, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 13.1625 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.625 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.1625 } ], "minimum": 13.1625, "maximum": 14.625 } ] }, { "description": "HYDRALAZINE (APRESOLINE) INJ 20 MG/ML", "code_information": [ { "code": "17478-0934-15", "type": "NDC" }, { "code": "J0360", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 117, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.34 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.34 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 55.58, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 52.65 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 58.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 52.65 } ], "minimum": 6.34, "maximum": 58.5 } ] }, { "description": "DULOXETINE HCL (CYMBALTA) CAP 30 MG", "code_information": [ { "code": "23155-0655-10", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.18, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.31, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.031 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.59 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.031 } ], "minimum": 0.01, "maximum": 5.59 } ] }, { "description": "TRIAMTERENE/HCTZ CAP 37.5 MG/25 MG", "code_information": [ { "code": "24208-0585-59", "type": "NDC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "NEOMYCIN/POLYMYXIN B/DEX OPTH OINT", "code_information": [ { "code": "24208-0795-35", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 3.5, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 107.9, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 51.25, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 48.555 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 53.95 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 48.555 } ], "minimum": 48.555, "maximum": 53.95 } ] }, { "description": "NEOMYCIN/POLYMYXIN B/BACITRACIN PACK", "code_information": [ { "code": "35823-2400-29", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 0.9, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 13, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.18, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.85 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.85 } ], "minimum": 5.85, "maximum": 6.5 } ] }, { "description": "METOPROLOL TART INJ 5 MG/5 ML", "code_information": [ { "code": "36000-0033-10", "type": "NDC" }, { "code": "J0616", "type": "HCPCS" } ], "drug_information": { "unit": 5, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.13 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.13 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 0.13, "maximum": 9.75 } ] }, { "description": "GELATIN SPONGE, UNCOMPRESSED : SIZE 100", "code_information": [ { "code": "36000-0048-24", "type": "NDC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 137, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 65.08, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 61.65 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 68.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 61.65 } ], "minimum": 61.65, "maximum": 68.5 } ] }, { "description": "FUROSEMIDE (LASIX) INJ 20 MG/2 ML", "code_information": [ { "code": "36000-0063-05", "type": "NDC" }, { "code": "J1941", "type": "HCPCS" } ], "drug_information": { "unit": 2, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 221.94 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 221.94 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 8.775, "maximum": 221.94 } ] }, { "description": "0.45% NACL INJ : 1000 ML", "code_information": [ { "code": "37205-0754-11", "type": "NDC" }, { "code": "J7030", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 58.5, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7275, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2.84 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2.84 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7275, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7275, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7275, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 27.79, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 26.325 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.325 } ], "minimum": 2.84, "maximum": 29.25 } ] }, { "description": "MULTIVITAMIN TABLET", "code_information": [ { "code": "38485-0120-41", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "IBUPROFEN (MOTRIN) TAB 800 MG", "code_information": [ { "code": "39822-2000-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "GABAPENTIN (NEURONTIN) CAP 400 MG", "code_information": [ { "code": "41616-0882-44", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.13, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.86, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.6585 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.065 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.6585 } ], "minimum": 3.6585, "maximum": 4.065 } ] }, { "description": "KETAMINE INJ : 50 MG/ML 10 ML", "code_information": [ { "code": "42023-0114-10", "type": "NDC" }, { "code": "J3490", "type": "HCPCS" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 74.1, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.5215, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.5215, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.5215, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.5215, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 35.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 33.345 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 37.05 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 33.345 } ], "minimum": 8.5215, "maximum": 37.05 } ] }, { "description": "Bupivacaine Liposome 1.3% 266mg/20ml", "code_information": [ { "code": "42023-0139-10", "type": "NDC" } ], "drug_information": { "unit": 20, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 3110, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1477.25, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1399.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1555 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1399.5 } ], "minimum": 1399.5, "maximum": 1555 } ] }, { "description": "VANCOMYCIN INJ : 500 MG", "code_information": [ { "code": "42023-0164-25", "type": "NDC" } ], "drug_information": { "unit": 500, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 15.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 7.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.876 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.876 } ], "minimum": 6.876, "maximum": 7.64 } ] }, { "description": "BACITRACIN ZINC OINTMENT 500U/1GM 14GM", "code_information": [ { "code": "42571-0137-25", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 14, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.575 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.575 } ], "minimum": 10.575, "maximum": 11.75 } ] }, { "description": "CLONAZEPAM (KLONOPIN) TAB 0.5 MG", "code_information": [ { "code": "43547-0406-10", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "AMLODIPINE (NORVASC) TAB 10 MG", "code_information": [ { "code": "43825-0102-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "CEFTRIAXONE (ROCEPHIN) INJ 1 GM VIAL", "code_information": [ { "code": "44567-0701-25", "type": "NDC" }, { "code": "J0696", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 298.67, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 34.34705, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.52 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 34.34705, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 34.34705, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 34.34705, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 141.87, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 134.4015 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 149.335 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 134.4015 } ], "minimum": 0.52, "maximum": 149.335 } ] }, { "description": "CETYLPYRIDINIUM CL (CEPACOL) 0.05% 24 OZ", "code_information": [ { "code": "44567-0840-25", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 720, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 51.03, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.24, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 22.9635 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.515 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.9635 } ], "minimum": 22.9635, "maximum": 25.515 } ] }, { "description": "KETOROLAC TROMET OPHTH SOLN 0.5%-5ml", "code_information": [ { "code": "44567-0845-25", "type": "NDC" }, { "code": "J3490", "type": "HCPCS" } ], "drug_information": { "unit": 5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 689, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 79.235, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 79.235, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 79.235, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 79.235, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 327.28, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 310.05 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 344.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 310.05 } ], "minimum": 79.235, "maximum": 344.5 } ] }, { "description": "MUPIROCIN (BACTROBAN) OINT 2% 22 GM", "code_information": [ { "code": "45802-0112-22", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 22, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 162.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 77.19, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 73.125 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 81.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 73.125 } ], "minimum": 73.125, "maximum": 81.25 } ] }, { "description": "KETOROLAC (TORODOL) INJ 30 MG/1 ML", "code_information": [ { "code": "47781-0584-68", "type": "NDC" }, { "code": "J1885", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.93, "discounted_cash": 0.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.67 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.67 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 0.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 0.41, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 0.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 0.294, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.19, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1.84, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 0.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 0.48, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 0.82, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 0.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 0.31 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 22.9185 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.465 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.9185 } ], "minimum": 0.294, "maximum": 25.465 } ] }, { "description": "CLONIDINE INJ 100 MCG/ML, 10 ML", "code_information": [ { "code": "47781-0597-91", "type": "NDC" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 273, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 129.68, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 122.85 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 136.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 122.85 } ], "minimum": 122.85, "maximum": 136.5 } ] }, { "description": "LEVOFLOXACIN 750 MG/D5W 150ML PREMIX BAG", "code_information": [ { "code": "47781-1044-04", "type": "NDC" } ], "drug_information": { "unit": 750, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 58.18, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 27.64, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 26.181 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.09 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.181 } ], "minimum": 26.181, "maximum": 29.09 } ] }, { "description": "DOXYCYCLINE (VIBRAMYCIN) CAP 100 MG", "code_information": [ { "code": "49884-0727-03", "type": "NDC" }, { "code": "J3490", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 9.43, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.08445, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.08445, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.08445, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.08445, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.48, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.2435 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.715 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.2435 } ], "minimum": 1.08445, "maximum": 4.715 } ] }, { "description": "AMLODIPINE (NORVASC) TAB 5 MG", "code_information": [ { "code": "50268-0084-11", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 22.75, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 10.81, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.2375 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.375 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.2375 } ], "minimum": 0.01, "maximum": 11.375 } ] }, { "description": "BETHANECHOL (URECHOLINE) TAB 25 MG", "code_information": [ { "code": "50268-0114-15", "type": "NDC" }, { "code": "J3490", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 17.55, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.01825, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.01825, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.01825, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.01825, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 8.34, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7.8975 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.8975 } ], "minimum": 2.01825, "maximum": 8.775 } ] }, { "description": "CALCIUM CARB (TUMS) TAB 500 MG CHEW", "code_information": [ { "code": "50268-0149-11", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "LOSARTAN POT (COZAAR) TAB 25 MG", "code_information": [ { "code": "50268-0504-11", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "MELOXICAM (MOBIC) TAB 7.5 MG", "code_information": [ { "code": "50268-0525-15", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "METOPROLOL SUCC (TOPROL XL) TAB 25 MG", "code_information": [ { "code": "50268-0540-11", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.83, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.24, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.0735 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.415 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.0735 } ], "minimum": 3.0735, "maximum": 3.415 } ] }, { "description": "LOSARTAN POT (COZAAR) TAB 100 MG", "code_information": [ { "code": "50268-0575-11", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 20.15, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.57, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9.0675 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.075 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.0675 } ], "minimum": 9.0675, "maximum": 10.075 } ] }, { "description": "PANTOPRAZOLE (PROTONIX) TAB 40 MG", "code_information": [ { "code": "50268-0639-11", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "OXYCODONE/ACET TAB 5 MG/325 MG", "code_information": [ { "code": "50268-0644-15", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.9, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.005 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.45 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.005 } ], "minimum": 4.005, "maximum": 4.45 } ] }, { "description": "SUCRALFATE (CARAFATE) TAB 1 GM", "code_information": [ { "code": "50268-0729-11", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "ROCURONIUM INJ : 50 MG/5 ML VIAL", "code_information": [ { "code": "50742-5050-01", "type": "NDC" } ], "drug_information": { "unit": 50, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 68.25, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 32.42, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 30.7125 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 34.125 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 30.7125 } ], "minimum": 30.7125, "maximum": 34.125 } ] }, { "description": "FUROSEMIDE (LASIX) TAB 20 MG", "code_information": [ { "code": "51079-0072-20", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "DIAZEPAM (VALIUM) TAB 5 MG", "code_information": [ { "code": "51079-0285-01", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "LEVOTHYROXINE TAB 100 MCG", "code_information": [ { "code": "51079-0442-20", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "LEVOTHYROXINE TAB 125 MCG", "code_information": [ { "code": "51079-0443-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.78, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.17, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.951 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.39 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.951 } ], "minimum": 3.951, "maximum": 4.39 } ] }, { "description": "ROPIVACAINE 0.5% 30 ML VIAL", "code_information": [ { "code": "51079-0558-01", "type": "NDC" } ], "drug_information": { "unit": 30, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 69.06, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 32.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 31.077 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 34.53 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 31.077 } ], "minimum": 31.077, "maximum": 34.53 } ] }, { "description": "LOPERAMIDE (IMMODIUM) CAP 2 MG", "code_information": [ { "code": "51079-0690-20", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "HYDROCHLOROTHIAZIDE CAP 12.5 MG", "code_information": [ { "code": "51079-0724-20", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "CARVEDILOL (COREG) TAB 3.125 MG", "code_information": [ { "code": "51079-0771-01", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.65, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.48, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.1425 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.825 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.1425 } ], "minimum": 0.01, "maximum": 6.825 } ] }, { "description": "VITAMIN D3 TAB 1000 IU", "code_information": [ { "code": "51079-0776-20", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "PRAVASTATIN (PRAVACHOL) TAB 10 MG", "code_information": [ { "code": "51079-0782-20", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "GLIPIZIDE-(GLUCOTROL) TAB 10 MG", "code_information": [ { "code": "51079-0811-20", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "VASOPRESSIN (VASOTRICT) INJ 20 UNIT/ML", "code_information": [ { "code": "51079-0894-20", "type": "NDC" } ], "drug_information": { "unit": 1, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 390, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 185.25, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 175.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 195 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 175.5 } ], "minimum": 175.5, "maximum": 195 } ] }, { "description": "CARVEDILOL (COREG) TAB 25 MG", "code_information": [ { "code": "51079-0932-01", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "TRIAMCINOLONE ACET. INJ : 40 MG/ML", "code_information": [ { "code": "51079-0935-01", "type": "NDC" } ], "drug_information": { "unit": 40, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 39, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 18.53, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 17.55 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.55 } ], "minimum": 17.55, "maximum": 19.5 } ] }, { "description": "ENALAPRIL (VASOTEC) TAB 5 MG", "code_information": [ { "code": "51079-0951-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 12.03, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.71, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.4135 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.015 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.4135 } ], "minimum": 5.4135, "maximum": 6.015 } ] }, { "description": "DIPHENHYDRAMINE (BENADRYL) CAP 25 MG", "code_information": [ { "code": "51079-0967-20", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "VANCOMYCIN INJ : 50 MG", "code_information": [ { "code": "51079-0981-20", "type": "NDC" } ], "drug_information": { "unit": 50, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.2, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.95, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.79 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.79 } ], "minimum": 2.79, "maximum": 3.1 } ] }, { "description": "BUSPIRONE (BUSPAR) TAB 5 MG", "code_information": [ { "code": "51079-0985-20", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "INFLUENZA VAC (QUADRIVAL) INJ 0.5 ML", "code_information": [ { "code": "52533-0067-12", "type": "NDC" } ], "drug_information": { "unit": 0.5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 106.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 50.64, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 47.97 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 53.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 47.97 } ], "minimum": 47.97, "maximum": 53.3 } ] }, { "description": "METHYLENE BLUE INJ : 5 MG/ML 10 ML", "code_information": [ { "code": "55150-0167-10", "type": "NDC" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 2031.35, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 964.89, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 914.1075 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1015.675 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 914.1075 } ], "minimum": 914.1075, "maximum": 1015.675 } ] }, { "description": "BUPIVACAINE MPF INJ : 0.25% 30 ML", "code_information": [ { "code": "55150-0168-30", "type": "NDC" }, { "code": "J0665", "type": "HCPCS" } ], "drug_information": { "unit": 30, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 20.8, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.02 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.88, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9.36 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.36 } ], "minimum": 0.01, "maximum": 10.4 } ] }, { "description": "RAMIPRIL (ALTACE) CAP 5 MG", "code_information": [ { "code": "55150-0225-05", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "DEXAMETHASONE (DECADRON) INJ 4 MG/ML 1ML", "code_information": [ { "code": "55150-0237-01", "type": "NDC" }, { "code": "J1100", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.1 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.14 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 0.1, "maximum": 9.75 } ] }, { "description": "HALOPERIDOL (HALDOL) INJ 5 MG/ML", "code_information": [ { "code": "55390-0147-10", "type": "NDC" }, { "code": "J1630", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 52.65, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1.36 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1.36 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 25.01, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 23.6925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.325 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.6925 } ], "minimum": 1.36, "maximum": 26.325 } ] }, { "description": "DESMOPRESSIN (DDAVP) INJ : 4MCG/ML 10 ML", "code_information": [ { "code": "55566-5040-01", "type": "NDC" }, { "code": "J2597", "type": "HCPCS" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 1300, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.77 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.77 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 617.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 12.1, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 5.44, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 585 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 650 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 585 } ], "minimum": 5.44, "maximum": 650 } ] }, { "description": "PHENOL SORE THROAT SPY 1.4% 177 ML", "code_information": [ { "code": "57841-1301-03", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 177, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 32.43, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 15.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 14.5935 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.215 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.5935 } ], "minimum": 14.5935, "maximum": 16.215 } ] }, { "description": "THIAMINE (VIT B-1) TAB 100 MG", "code_information": [ { "code": "57896-0841-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "DICYCLOMINE (BENTYL) CAP 10 MG", "code_information": [ { "code": "58914-0012-10", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "GLYCERIN SUPP ADULT", "code_information": [ { "code": "58980-0410-12", "type": "NDC" }, { "code": "J3490", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 13, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.495, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.495, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.495, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.495, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.18, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.85 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.85 } ], "minimum": 1.495, "maximum": 6.5 } ] }, { "description": "OXYCODONE CR (OXYCONTIN) TAB 10 MG", "code_information": [ { "code": "59011-0410-20", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 45.37, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 20.4165 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.685 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.4165 } ], "minimum": 20.4165, "maximum": 22.685 } ] }, { "description": "THROMBIN/GELATIN BOVINE (FLOSEAL) : 5ML", "code_information": [ { "code": "59011-0420-20", "type": "NDC" } ], "drug_information": { "unit": 5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 1892.25, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 898.82, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 851.5125 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 946.125 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 851.5125 } ], "minimum": 851.5125, "maximum": 946.125 } ] }, { "description": "DIPHENOXYLATE/ATROP TAB 2.5/0.025 MG", "code_information": [ { "code": "59762-1061-01", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "NITROGLYCERIN SL TAB 0.4 MG", "code_information": [ { "code": "59762-3304-03", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 99.78, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 47.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 44.901 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 49.89 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 44.901 } ], "minimum": 44.901, "maximum": 49.89 } ] }, { "description": "NYSTATIN POWDER 100,000 MU/GM, 15 GM", "code_information": [ { "code": "60432-0537-16", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 15, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 151.32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 71.88, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 68.094 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 75.66 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 68.094 } ], "minimum": 68.094, "maximum": 75.66 } ] }, { "description": "GABAPENTIN (NEURONTIN) CAP 100 MG", "code_information": [ { "code": "60505-0112-00", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "CLOPIDOGREL (PLAVIX) TAB : 300 MG", "code_information": [ { "code": "60505-0706-20", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 125.45, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 59.59, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 56.4525 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 62.725 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 56.4525 } ], "minimum": 56.4525, "maximum": 62.725 } ] }, { "description": "CEFAZOLIN INJ 1GM", "code_information": [ { "code": "60505-6142-00", "type": "NDC" }, { "code": "J0687", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1.07 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1.07 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 1.07, "maximum": 9.75 } ] }, { "description": "DILTIAZEM (CARDIZEM) CD CAP 180 MG", "code_information": [ { "code": "60687-0206-11", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "HYDROCODONE/ACET (NORCO) TAB 7.5/325", "code_information": [ { "code": "60687-0407-11", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "TRAMADOL (ULTRAM) TAB 50 MG", "code_information": [ { "code": "60687-0443-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "TOBRAMYCIN/DEX OPH OINT : 0.3%/0.1%", "code_information": [ { "code": "60687-0795-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 3.5, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 2325.12, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1104.43, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1046.304 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1162.56 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1046.304 } ], "minimum": 1046.304, "maximum": 1162.56 } ] }, { "description": "PHENOL SORE THROAT SPY 1.4% 20 ML", "code_information": [ { "code": "60793-0215-05", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 20, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 20.15, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.57, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9.0675 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.075 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.0675 } ], "minimum": 9.0675, "maximum": 10.075 } ] }, { "description": "VANCOMYCIN INJ 1500 MG", "code_information": [ { "code": "61269-0105-34", "type": "NDC" } ], "drug_information": { "unit": 1500, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 188.18, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 89.39, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 84.681 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 94.09 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 84.681 } ], "minimum": 84.681, "maximum": 94.09 } ] }, { "description": "OFLOXACIN (FLOXIN) OTIC SOLN : 0.3%", "code_information": [ { "code": "61314-0015-05", "type": "NDC" } ], "drug_information": { "unit": 5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 257.28, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 122.21, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 115.776 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 128.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 115.776 } ], "minimum": 115.776, "maximum": 128.64 } ] }, { "description": "BUPIVACAINE/EPI-MPF INJ : 0.25% 30 ML", "code_information": [ { "code": "61990-0611-00", "type": "NDC" } ], "drug_information": { "unit": 30, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 90.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.99, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 40.725 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 45.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 40.725 } ], "minimum": 40.725, "maximum": 45.25 } ] }, { "description": "METOPROLOL SUCC (TOPROL XL) TAB 50 MG", "code_information": [ { "code": "62037-0831-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "FOLIC ACID (FOLVITE) TAB 1 MG", "code_information": [ { "code": "62584-0897-11", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "SULFAMETHOXAZOLE/TMP TAB 800/160 MG", "code_information": [ { "code": "62756-0521-69", "type": "NDC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "GENTAMICIN INJ 80 MG/2 ML VIAL", "code_information": [ { "code": "63323-0010-02", "type": "NDC" }, { "code": "J1580", "type": "HCPCS" } ], "drug_information": { "unit": 2, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 31.75, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.65125, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3.21 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.65125, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.65125, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.65125, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 15.08, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 14.2875 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.875 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.2875 } ], "minimum": 3.21, "maximum": 15.875 } ] }, { "description": "MAGNESIUM SULF 1 GM/100 ML D5 PREMIX", "code_information": [ { "code": "63323-0108-01", "type": "NDC" }, { "code": "J3475", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 24.49, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.84 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.84 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.63, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 11.0205 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.245 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.0205 } ], "minimum": 0.84, "maximum": 12.245 } ] }, { "description": "MEDICINAL SPIRITS : BEER", "code_information": [ { "code": "63323-0185-10", "type": "NDC" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.73, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.27, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.6785 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.865 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.6785 } ], "minimum": 10.6785, "maximum": 11.865 } ] }, { "description": "PROPOFOL (DIPRIVAN) INJ 1000 MG/100 ML", "code_information": [ { "code": "63323-0269-29", "type": "NDC" } ], "drug_information": { "unit": 1000, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 93.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 44.46, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 42.12 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 46.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 42.12 } ], "minimum": 42.12, "maximum": 46.8 } ] }, { "description": "MILK OF MAGNESIA : 355ml", "code_information": [ { "code": "63323-0286-20", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 355, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 34.39, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.34, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.4755 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.195 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.4755 } ], "minimum": 15.4755, "maximum": 17.195 } ] }, { "description": "MIDAZOLAM (VERSED) INJ : 5 MG/5 ML VIAL", "code_information": [ { "code": "63323-0286-35", "type": "NDC" } ], "drug_information": { "unit": 5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 22.43, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 10.65, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.0935 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.215 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.0935 } ], "minimum": 10.0935, "maximum": 11.215 } ] }, { "description": "BACITRACIN OINT 28GM", "code_information": [ { "code": "63323-0411-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 34.13, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.21, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.3585 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.065 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.3585 } ], "minimum": 15.3585, "maximum": 17.065 } ] }, { "description": "LIDOCAINE INJ MPF : 1% 5 ML", "code_information": [ { "code": "63323-04-5400", "type": "NDC" } ], "drug_information": { "unit": 5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 30.75, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 14.61, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 13.8375 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.375 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.8375 } ], "minimum": 13.8375, "maximum": 15.375 } ] }, { "description": "LIDOCAINE 2% (GLYDO) URO-JECT 11 ML", "code_information": [ { "code": "63323-0461-57", "type": "NDC" } ], "drug_information": { "unit": 11, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 49.53, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 23.53, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 22.2885 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 24.765 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.2885 } ], "minimum": 22.2885, "maximum": 24.765 } ] }, { "description": "SOD CHLORIDE INJ 0.9% 10 ML PF", "code_information": [ { "code": "63323-0492-89", "type": "NDC" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 8.775, "maximum": 9.75 } ] }, { "description": "LIDOCAINE 2% 5 ML VIAL", "code_information": [ { "code": "63323-0495-07", "type": "NDC" }, { "code": "J2003", "type": "HCPCS" } ], "drug_information": { "unit": 5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 28, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 12.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 14 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.6 } ], "minimum": 0.01, "maximum": 14 } ] }, { "description": "DEXAMETHASONE (DECADRON) INJ 10MG/ML 1ML", "code_information": [ { "code": "63323-0506-01", "type": "NDC" }, { "code": "J1100", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.1 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.14 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 0.1, "maximum": 9.75 } ] }, { "description": "HEPARIN INJ 1,000 UNITS/ML 10 ML VIAL", "code_information": [ { "code": "63323-0540-31", "type": "NDC" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 56.88, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 27.02, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 25.596 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 28.44 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.596 } ], "minimum": 25.596, "maximum": 28.44 } ] }, { "description": "DIPHENHYDRAMINE (BENADRYL) INJ 50MG/ML", "code_information": [ { "code": "63323-0664-01", "type": "NDC" }, { "code": "J1200", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.48, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.7002, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.94 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.94 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.7002, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.7002, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.7002, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.15, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.566 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.74 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.566 } ], "minimum": 0.94, "maximum": 11.74 } ] }, { "description": "HYDROMORPHONE (DILAUDID) INJ 1 MG", "code_information": [ { "code": "63323-0852-03", "type": "NDC" }, { "code": "J1171", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 20.28, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.11 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.11 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.63, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 0.22, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9.126 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.14 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.126 } ], "minimum": 0.11, "maximum": 10.14 } ] }, { "description": "Gelatin Sponge Size 50", "code_information": [ { "code": "63713-0019-73", "type": "NDC" }, { "code": "250", "type": "RC" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 115.78, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 52.101 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 57.89 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 52.101 } ], "minimum": 52.101, "maximum": 57.89 } ] }, { "description": "VANCOMYCIN IVPB: 1000MG /NS 250 ML", "code_information": [ { "code": "63713-0019-73", "type": "NDC" } ], "drug_information": { "unit": 1000, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 175.25, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 83.24, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 78.8625 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 87.625 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 78.8625 } ], "minimum": 78.8625, "maximum": 87.625 } ] }, { "description": "CLONIDINE (CATAPRES) TAB 0.1 MG", "code_information": [ { "code": "63739-0060-10", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "HYDROCHLOROTHIAZIDE TAB 25 MG", "code_information": [ { "code": "63739-0128-10", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "SILVER SULFADIAZINE CREAM 25 GM", "code_information": [ { "code": "63739-0225-10", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 25, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 88.08, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 41.84, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 39.636 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 44.04 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 39.636 } ], "minimum": 39.636, "maximum": 44.04 } ] }, { "description": "MAGNESIUM OXIDE (MAG-OX) TAB 400 MG", "code_information": [ { "code": "63739-0354-10", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "ACETAMINOPHEN (TYLENOL) TAB 325 MG", "code_information": [ { "code": "63739-0440-01", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "PEG 3350 (MIRALAX) PACKET 17 GM", "code_information": [ { "code": "63739-0446-10", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 17, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.71, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.51 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.51 } ], "minimum": 3.51, "maximum": 3.9 } ] }, { "description": "PRAVASTATIN (PRAVACHOL) TAB 40 MG", "code_information": [ { "code": "63739-0518-10", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.08, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.79, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.536 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.04 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.536 } ], "minimum": 4.536, "maximum": 5.04 } ] }, { "description": "ASPIRIN EC TAB 325 MG", "code_information": [ { "code": "63739-0523-01", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "SOTALOL HCL (BETAPACE) TAB 80 MG", "code_information": [ { "code": "63739-0544-10", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 15.08, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 7.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.786 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.54 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.786 } ], "minimum": 6.786, "maximum": 7.54 } ] }, { "description": "FAMOTIDINE (PEPCID) TAB 20 MG", "code_information": [ { "code": "63739-0645-10", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "TAMSULOSIN (FLOMAX) CAP 0.4 MG", "code_information": [ { "code": "63739-0877-10", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "HEPARIN LOCK 100 UNITS/ML 5 ML PFS", "code_information": [ { "code": "63807-0600-05", "type": "NDC" }, { "code": "J1642", "type": "HCPCS" } ], "drug_information": { "unit": 5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.02 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.02 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 0.02, "maximum": 9.75 } ] }, { "description": "GUAIFENESIN (MUCINEX) TAB 600 MG", "code_information": [ { "code": "63824-0008-32", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "GUAIFENESIN/D-METH TAB 600/30 MG", "code_information": [ { "code": "63824-0056-34", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "SHUGAR-CAINE INJ : 1 ML", "code_information": [ { "code": "63824-0790-80", "type": "NDC" } ], "drug_information": { "unit": 1, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 144.3, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 68.54, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 64.935 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 72.15 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 64.935 } ], "minimum": 64.935, "maximum": 72.15 } ] }, { "description": "LACTOBACILLUS (FLORANEX) GRAN 1GM", "code_information": [ { "code": "64980-1469-08", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 13.33, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.9985 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.665 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.9985 } ], "minimum": 0.01, "maximum": 6.665 } ] }, { "description": "PHENYLEPHRINE OPTH SOLN : 10% 5 ML", "code_information": [ { "code": "65145-1511-00", "type": "NDC" } ], "drug_information": { "unit": 5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 325, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 154.38, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 146.25 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 162.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 146.25 } ], "minimum": 146.25, "maximum": 162.5 } ] }, { "description": "TRANEXAMIC ACID INJ 100MG/ML 10ML", "code_information": [ { "code": "65250-0133-04", "type": "NDC" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 48.75, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 23.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 21.9375 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 24.375 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.9375 } ], "minimum": 21.9375, "maximum": 24.375 } ] }, { "description": "WATER FOR INJECTION 10 ML", "code_information": [ { "code": "65250-0266-20", "type": "NDC" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 34.25, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 16.27, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.4125 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.125 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.4125 } ], "minimum": 15.4125, "maximum": 17.125 } ] }, { "description": "PROPRANOLOL (INDERAL) TAB 20 MG", "code_information": [ { "code": "65862-0476-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "HYDROCODONE/ACET SOLN 7.5/325 MG 15 ML", "code_information": [ { "code": "66689-0023-01", "type": "NDC" }, { "code": "J8499", "type": "HCPCS" } ], "drug_information": { "unit": 15, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 32, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 15.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 14.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.4 } ], "minimum": 14.4, "maximum": 16 } ] }, { "description": "LACTULOSE SOLN 20 GM/30 ML", "code_information": [ { "code": "66689-0038-50", "type": "NDC" }, { "code": "J3490", "type": "HCPCS" } ], "drug_information": { "unit": 30, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.8, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 0.897, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 0.897, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 0.897, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 0.897, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.71, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.51 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.51 } ], "minimum": 0.897, "maximum": 3.9 } ] }, { "description": "ESMOLOL (BREVIBLOC) INJ : 100 MG/10 ML", "code_information": [ { "code": "67457-0182-10", "type": "NDC" }, { "code": "J1805", "type": "HCPCS" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 56.88, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.28 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 27.02, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 25.596 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 28.44 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.596 } ], "minimum": 0.28, "maximum": 28.44 } ] }, { "description": "NALOXONE (NARCAN) INJ 0.4 MG/ML", "code_information": [ { "code": "67457-0292-02", "type": "NDC" }, { "code": "J2310", "type": "HCPCS" } ], "drug_information": { "unit": 0.4, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 123.44, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.1956, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 10.49 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 10.49 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.1956, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.1956, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 14.1956, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 58.63, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 55.548 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 61.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 55.548 } ], "minimum": 10.49, "maximum": 61.72 } ] }, { "description": "SUGAMMADEX INJ 100 MG/ML 2 ML VIAL", "code_information": [ { "code": "67457-0823-99", "type": "NDC" } ], "drug_information": { "unit": 2, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 1062, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 504.45, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 477.9 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 531 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 477.9 } ], "minimum": 477.9, "maximum": 531 } ] }, { "description": "ROPIVACAINE 1% 20 ML VIAL", "code_information": [ { "code": "67877-0321-01", "type": "NDC" } ], "drug_information": { "unit": 20, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 140.4, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 66.69, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 63.18 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 70.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 63.18 } ], "minimum": 63.18, "maximum": 70.2 } ] }, { "description": "DAPTOMYCIN (CUBICIN) INJ : 500 MG", "code_information": [ { "code": "67919-0011-01", "type": "NDC" }, { "code": "J0878", "type": "HCPCS" } ], "drug_information": { "unit": 500, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 154, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.04 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.04 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 73.15, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 69.3 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 77 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 69.3 } ], "minimum": 0.04, "maximum": 77 } ] }, { "description": "ATORVASTATIN (LIPITOR) TAB 40 MG", "code_information": [ { "code": "68084-0099-01", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "HYDROXYZINE HCL (ATARAX) TAB 25 MG", "code_information": [ { "code": "68084-0254-11", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "POTASSIUM CL (KLOR-CON) TAB 10 MEQ", "code_information": [ { "code": "68084-0360-11", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "HYDROMORPHONE (DILAUDID) TAB 2 MG", "code_information": [ { "code": "68084-0423-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "NICARDIPINE INJ : 25 MG/10 ML", "code_information": [ { "code": "68084-0469-01", "type": "NDC" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 239.85, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 113.93, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 107.9325 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 119.925 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 107.9325 } ], "minimum": 107.9325, "maximum": 119.925 } ] }, { "description": "LEVOFLOXACIN (LEVAQUIN) TAB 250 MG", "code_information": [ { "code": "68084-0481-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 95.71, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 45.46, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 43.0695 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 47.855 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 43.0695 } ], "minimum": 43.0695, "maximum": 47.855 } ] }, { "description": "POTASSIUM CL (KLOR-CON) TAB 20 MEQ", "code_information": [ { "code": "68084-0500-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "NIFEDIPINE ER (ADALAT CC) TAB 30 MG", "code_information": [ { "code": "68084-0597-11", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.53, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.8385 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.265 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.8385 } ], "minimum": 3.8385, "maximum": 4.265 } ] }, { "description": "TETRACAINE OPTH SOLN : 0.5% 4 ML", "code_information": [ { "code": "68084-0645-01", "type": "NDC" } ], "drug_information": { "unit": 4, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 108.26, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 51.42, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 48.717 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 54.13 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 48.717 } ], "minimum": 48.717, "maximum": 54.13 } ] }, { "description": "VANCOMYCIN IVPB : 1500 MG/NS 250 ML", "code_information": [ { "code": "68084-0774-01", "type": "NDC" } ], "drug_information": { "unit": 1500, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 238.18, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 113.14, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 107.181 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 119.09 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 107.181 } ], "minimum": 107.181, "maximum": 119.09 } ] }, { "description": "HYDROXYZINE PAMOATE CAP 25 MG", "code_information": [ { "code": "68084-0847-11", "type": "NDC" }, { "code": "Q0177", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.21 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.21, "maximum": 3.25 } ] }, { "description": "HYDROCODONE/ACET (NORCO) TAB 10/325 MG", "code_information": [ { "code": "68084-0884-11", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.86, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.73, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.537 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.93 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.537 } ], "minimum": 3.537, "maximum": 3.93 } ] }, { "description": "OXYCODONE IR (ROXICODONE) TAB 15 MG", "code_information": [ { "code": "68094-0005-61", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "CARVEDILOL (COREG) TAB 6.25 MG", "code_information": [ { "code": "68382-0093-01", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "ETOMIDATE (AMIDATE) INJ : 20MG/10ML", "code_information": [ { "code": "68382-0545-07", "type": "NDC" }, { "code": "J3490", "type": "HCPCS" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 42.9, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.9335, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.9335, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.9335, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.9335, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 20.38, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 19.305 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.45 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.305 } ], "minimum": 4.9335, "maximum": 21.45 } ] }, { "description": "ONDANSETRON (ZOFRAN) ODT TAB 4 MG", "code_information": [ { "code": "68462-0157-40", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 150.48, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 71.48, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 67.716 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 75.24 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 67.716 } ], "minimum": 67.716, "maximum": 75.24 } ] }, { "description": "TROPICAMIDE (MYDRIACIL) OPH SOL : 1%", "code_information": [ { "code": "68803-0612-01", "type": "NDC" } ], "drug_information": { "unit": 3, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 91, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 43.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 40.95 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 45.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 40.95 } ], "minimum": 40.95, "maximum": 45.5 } ] }, { "description": "ALBUMIN INJ 5% : 25 GM/500 ML", "code_information": [ { "code": "68982-0623-03", "type": "NDC" }, { "code": "P9045", "type": "HCPCS" } ], "drug_information": { "unit": 500, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 1404, "discounted_cash": 94.28, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 58.39 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 58.39 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.14, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 63.64, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.14, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 57.0394, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 46.1972, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 666.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 129.64, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.14, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 75.424, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 58.33, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 47.14, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 49.03 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 631.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 702 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 631.8 } ], "minimum": 46.1972, "maximum": 702 } ] }, { "description": "ALFUZOSIN HCL (UROXATRAL) TAB 10 MG", "code_information": [ { "code": "69097-0844-07", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 27.38, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.01, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 12.321 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.69 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.321 } ], "minimum": 0.01, "maximum": 13.69 } ] }, { "description": "CYCLOBENZAPRINE (FLEXERIL) TAB 10 MG", "code_information": [ { "code": "69097-0846-07", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "ASPIRIN EC TAB 81 MG", "code_information": [ { "code": "70000-0178-01", "type": "NDC" }, { "code": "A9270", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 0.01, "maximum": 3.25 } ] }, { "description": "METHOCARBAMOL (ROBAXIN) TAB 750 MG", "code_information": [ { "code": "70010-0770-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "VERAPAMIL ER (CALAN SR) TAB 120 MG", "code_information": [ { "code": "70069-0271-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.13, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.86, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.6585 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.065 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.6585 } ], "minimum": 3.6585, "maximum": 4.065 } ] }, { "description": "PRECEDEX INJECTION 100MCG/ML", "code_information": [ { "code": "70382-0204-01", "type": "NDC" } ], "drug_information": { "unit": 1, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 46.75, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 22.21, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 21.0375 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.375 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.0375 } ], "minimum": 21.0375, "maximum": 23.375 } ] }, { "description": "CEPHALEXIN (KEFLEX) CAP 500 MG", "code_information": [ { "code": "70461-0322-04", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 500, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "FLUCONAZOLE (DIFLUCAN) INJ 200 MG", "code_information": [ { "code": "70655-0002-06", "type": "NDC" }, { "code": "J1450", "type": "HCPCS" } ], "drug_information": { "unit": 200, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 70.25, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.07875, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2.57 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2.6 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.07875, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.07875, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.07875, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 33.37, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 31.6125 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 35.125 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 31.6125 } ], "minimum": 2.57, "maximum": 35.125 } ] }, { "description": "EPHEDRINE SO4 INJ : 50 MG/ML", "code_information": [ { "code": "70756-6118-02", "type": "NDC" }, { "code": "J3490", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.08, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 22.4342, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 22.4342, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 22.4342, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 22.4342, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 92.66, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 87.786 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 97.54 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 87.786 } ], "minimum": 22.4342, "maximum": 97.54 } ] }, { "description": "VANCOMYCIN INJ 1000 MG", "code_information": [ { "code": "70860-0104-41", "type": "NDC" } ], "drug_information": { "unit": 1000, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 125.11, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 59.43, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 56.2995 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 62.555 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 56.2995 } ], "minimum": 56.2995, "maximum": 62.555 } ] }, { "description": "ONDANSETRON (ZOFRAN) INJ 4 MG/2 ML", "code_information": [ { "code": "70860-0776-41", "type": "NDC" }, { "code": "J2405", "type": "HCPCS" } ], "drug_information": { "unit": 4, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.1 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.1 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 0.1, "maximum": 9.75 } ] }, { "description": "VALSARTAN (DIOVAN) TAB 160 MG", "code_information": [ { "code": "71288-0023-20", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "ENOXAPARIN (LOVENOX) INJ 30 MG", "code_information": [ { "code": "71288-0410-80", "type": "NDC" }, { "code": "J1650", "type": "HCPCS" } ], "drug_information": { "unit": 30, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 45.18, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.1957, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.74 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.73 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.1957, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.1957, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.1957, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.46, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 20.331 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.59 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.331 } ], "minimum": 0.73, "maximum": 22.59 } ] }, { "description": "GEL-FLOW KIT 5000UI;NO STRENGTH", "code_information": [ { "code": "71288-0505-03", "type": "NDC" } ], "drug_information": { "unit": 5000, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 1615.71, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 767.46, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 727.0695 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 807.855 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 727.0695 } ], "minimum": 727.0695, "maximum": 807.855 } ] }, { "description": "GEL-FLOW NT POWDER", "code_information": [ { "code": "71384-0640-01", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 951.8, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 452.11, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 428.31 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 475.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 428.31 } ], "minimum": 428.31, "maximum": 475.9 } ] }, { "description": "MAGNESIUM CITRATE SOLN 10 OZ", "code_information": [ { "code": "71399-7889-01", "type": "NDC" } ], "drug_information": { "unit": 300, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 22.95, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 10.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.3275 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.475 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.3275 } ], "minimum": 10.3275, "maximum": 11.475 } ] }, { "description": "NEOSTIGMINE 1 MG/ML INJ : 10 ML", "code_information": [ { "code": "76014-0003-10", "type": "NDC" }, { "code": "J2710", "type": "HCPCS" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 47, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1.94 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1.94 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 22.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 21.15 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.15 } ], "minimum": 1.94, "maximum": 23.5 } ] }, { "description": "THROMBIN TOPICAL 5,000 UNIT KIT", "code_information": [ { "code": "76204-0011-01", "type": "NDC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 576.75, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 273.96, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 259.5375 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 288.375 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 259.5375 } ], "minimum": 259.5375, "maximum": 288.375 } ] }, { "description": "EPINEPHRINE INJ : 1 MG/ML, 30 ML", "code_information": [ { "code": "76329-9061-00", "type": "NDC" }, { "code": "J0165", "type": "HCPCS" } ], "drug_information": { "unit": 30, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 1755, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.52 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 833.63, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 789.75 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 877.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 789.75 } ], "minimum": 0.52, "maximum": 877.5 } ] }, { "description": "PHENAZOPYRIDINE (PYRIDIUM) TAB 100 MG", "code_information": [ { "code": "87651-0241-53", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "HYDROCORTISONE (CORTEF) TAB 10 MG", "code_information": [ { "code": "99999-9999-17", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 13, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.18, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.85 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.85 } ], "minimum": 5.85, "maximum": 6.5 } ] }, { "description": "TOBRAMYCIN INJ : 1.2 GRAM", "code_information": [ { "code": "99999-9999-17", "type": "NDC" } ], "drug_information": { "unit": 1.2, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 561.6, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 266.76, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 252.72 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 280.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 252.72 } ], "minimum": 252.72, "maximum": 280.8 } ] }, { "description": "KETAMINE INJ 50 MG/ML, 1 ML SYRINGE", "code_information": [ { "code": "99999-9999-17", "type": "NDC" } ], "drug_information": { "unit": 1, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 29.25, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 13.89, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 13.1625 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.625 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 13.1625 } ], "minimum": 13.1625, "maximum": 14.625 } ] }, { "description": "VANCOMYCIN INJ 1250 MG", "code_information": [ { "code": "99999-9999-20", "type": "NDC" } ], "drug_information": { "unit": 1250, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 156.78, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 74.47, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 70.551 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 78.39 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 70.551 } ], "minimum": 70.551, "maximum": 78.39 } ] }, { "description": "MEDICINAL SPIRITS : BOURBON/WHISKEY 30ML", "code_information": [ { "code": "99999-9999-46", "type": "NDC" } ], "drug_information": { "unit": 30, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 32.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 15.44, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 14.625 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.625 } ], "minimum": 14.625, "maximum": 16.25 } ] }, { "description": "VIAL-MATE ADAPTER : EA", "code_information": [ { "code": "99999-9999-74", "type": "NDC" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.26, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 8.775, "maximum": 9.75 } ] }, { "description": "ALPRAZOLAM (XANAX) TAB 1 MG", "code_information": [ { "code": "99999-9999-85", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.5, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.09, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.925 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.925 } ], "minimum": 2.925, "maximum": 3.25 } ] }, { "description": "APIXABAN (ELIQUIS) TAB 2.5 MG", "code_information": [ { "code": "99999-9999-89", "type": "NDC" }, { "code": "637", "type": "RC" } ], "drug_information": { "unit": 1, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 78.82, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 37.44, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 35.469 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 39.41 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 35.469 } ], "minimum": 35.469, "maximum": 39.41 } ] }, { "description": "IMPLANT RESTRATA MESHED MATRIX ACERA", "code_information": [ { "code": "A2007", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15000, "discounted_cash": 225.84, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 141.15, "additional_payer_notes": "125% of medicare" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 112.92, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 220.33 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 223.16 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 112.92, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 152.44, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 112.92, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 136.6332, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 110.6616, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 7125, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 112.92, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 180.672, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 136.3, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 112.92, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 117.44 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6750 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6750 } ], "minimum": 110.6616, "maximum": 7500 } ] }, { "description": "IMPLANT RESTRATA 5X5 WOUND MATRIX ACERA", "code_information": [ { "code": "A2007", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9600, "discounted_cash": 225.84, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 141.15, "additional_payer_notes": "125% of medicare" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 112.92, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 220.33 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 223.16 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 112.92, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 152.44, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 112.92, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 136.6332, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 110.6616, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4560, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 112.92, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 180.672, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 136.3, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 112.92, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 117.44 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4320 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4800 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4320 } ], "minimum": 110.6616, "maximum": 4800 } ] }, { "description": "SALINE FLUSH 0.9% 10ML SYRINGE MEDLINE", "code_information": [ { "code": "A4216", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.64, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.45 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.45 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.78, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.738 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.82 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.738 } ], "minimum": 0.45, "maximum": 0.82 } ] }, { "description": "INTERSTIM TEMP TRIAL VERIFY", "code_information": [ { "code": "A4290", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1444, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 685.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 649.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 722 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 649.8 } ], "minimum": 0.01, "maximum": 722 } ] }, { "description": "AUTOPLEX W HV CEMENT", "code_information": [ { "code": "A4364", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4268.92, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3.42 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3.5 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2027.74, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1921.014 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2134.46 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1921.014 } ], "minimum": 3.42, "maximum": 2134.46 } ] }, { "description": "SUTURE SILK 2-0 KS", "code_information": [ { "code": "A4649", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.2, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.47, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.34 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.34 } ], "minimum": 0.01, "maximum": 2.6 } ] }, { "description": "MEPILEX BORDER 4X4 DRESSING MEDLINE", "code_information": [ { "code": "A6212", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.12, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 11.56 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.38, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.204 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.56 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.204 } ], "minimum": 3.204, "maximum": 11.56 } ] }, { "description": "MEPILEX BORDER 7X7 DRESSING MEDLINE", "code_information": [ { "code": "A6212", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 11.28 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 11.56 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.31, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.82 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.82 } ], "minimum": 8.82, "maximum": 11.56 } ] }, { "description": "XPERIENCE SURGICAL IRRIGATION", "code_information": [ { "code": "A6260", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 580, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 275.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 261 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 290 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 261 } ], "minimum": 0.01, "maximum": 290 } ] }, { "description": "BIASURGE SURGICAL IRRIGATION", "code_information": [ { "code": "A6260", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 720, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 342, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 324 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 360 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 324 } ], "minimum": 0.01, "maximum": 360 } ] }, { "description": "BACTISURE WOUND LAVAGE ZIMMER", "code_information": [ { "code": "A6260", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1425, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1350 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1350 } ], "minimum": 0.01, "maximum": 1500 } ] }, { "description": "PROHANCE 20ML PER/ML", "code_information": [ { "code": "A9579", "type": "HCPCS" }, { "code": "00270-1111-03", "type": "NDC" } ], "drug_information": { "unit": 1, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1.68 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1.68 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.61, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.42 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.42 } ], "minimum": 1.68, "maximum": 3.8 } ] }, { "description": "PATIENT PROGRAMMER PTM", "code_information": [ { "code": "A9900", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2684, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1274.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1207.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1342 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1207.8 } ], "minimum": 0.01, "maximum": 1342 } ] }, { "description": "CERAMENT G 10MM BONE VOID FILLER", "code_information": [ { "code": "C1602", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 80225, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 38106.88, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 36101.25 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 40112.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 36101.25 } ], "minimum": 0.01, "maximum": 40112.5 } ] }, { "description": "IMPLANT SET SCREW TLIF/PLIF VY SPINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 196, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 93.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 88.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 98 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 88.2 } ], "minimum": 0.01, "maximum": 98 } ] }, { "description": "IMPLANT 4.0MM VARIABLE SELF DRILL SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 411.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 195.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 185.22 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 205.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 185.22 } ], "minimum": 0.01, "maximum": 205.8 } ] }, { "description": "IMPLANT 6.5MM SCREW LUMBAR VY SPINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT 7.5MM SCREW LUMBAR VY SPIN", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT SCREW VARIABLE ACDF 2020 GCSDM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 411.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 195.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 185.22 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 205.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 185.22 } ], "minimum": 0.01, "maximum": 205.8 } ] }, { "description": "BONE CEMENT BC R BIOMET 2021 ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 278.84, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 132.45, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 125.478 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 139.42 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 125.478 } ], "minimum": 0.01, "maximum": 139.42 } ] }, { "description": "IMPLANT 7.5 SCREW LUMBAR VY SPINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT 6.5 SCREW LUMBAR VY SPINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT 4.0 SELF DRILLING VARIABLE SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 411.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 195.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 185.22 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 205.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 185.22 } ], "minimum": 0.01, "maximum": 205.8 } ] }, { "description": "IMPLANT 4.0 VARIABLE SCREW ZAVAT", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 411.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 195.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 185.22 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 205.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 185.22 } ], "minimum": 0.01, "maximum": 205.8 } ] }, { "description": "IMPLANT LUMBAR PLATE SCREW ZAVATION", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 784, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 372.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 352.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 392 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.8 } ], "minimum": 0.01, "maximum": 392 } ] }, { "description": "IMPLANT 4.0MM PCT SCREW VY SPINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT SET SCREW MONACO PED SYS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 196, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 93.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 88.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 98 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 88.2 } ], "minimum": 0.01, "maximum": 98 } ] }, { "description": "IMPLANT SET SCREW ZAVATION", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 196, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 93.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 88.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 98 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 88.2 } ], "minimum": 0.01, "maximum": 98 } ] }, { "description": "IMPLANT 4.0MM CC SELF DRILL FUJI SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 408, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 193.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 183.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 204 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 183.6 } ], "minimum": 0.01, "maximum": 204 } ] }, { "description": "IMPLANT SCREW ST VARIABLE ACDF GCSDM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 411.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 195.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 185.22 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 205.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 185.22 } ], "minimum": 0.01, "maximum": 205.8 } ] }, { "description": "IMPLANT SCREW 6.5 ZAVATION", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT 4.0 FIXED SELF DRILLING SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 411.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 195.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 185.22 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 205.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 185.22 } ], "minimum": 0.01, "maximum": 205.8 } ] }, { "description": "IMPLANT 4.0MM SCREW PCT VY SPINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT CURVED ROD HEX END VY SPINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 784, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 372.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 352.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 392 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.8 } ], "minimum": 0.01, "maximum": 392 } ] }, { "description": "IMPLANT VALENCIA LOCKING CAP ALTUS SPINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 196, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 93.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 88.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 98 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 88.2 } ], "minimum": 0.01, "maximum": 98 } ] }, { "description": "IMPLANT MONACO PEDICLE SCREW 7.5 ALTUS S", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT IFUSE 3D FOR SI JOINT SI-BONE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11600, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5510, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5220 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5800 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5220 } ], "minimum": 0.01, "maximum": 5800 } ] }, { "description": "IMPLANT BROADBAND LOOP MINI ZIMMERBIOM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 252, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 119.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 113.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 126 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 113.4 } ], "minimum": 0.01, "maximum": 126 } ] }, { "description": "IMPLANT BOWLINE 1CC DBM PUTTY TIDESMEDIC", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 660, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 313.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 297 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 330 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 297 } ], "minimum": 0.01, "maximum": 330 } ] }, { "description": "IMPLANT MEDIUM SCREW ANCHOR PISCESOSSEUS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1176, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 558.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 529.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 588 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 529.2 } ], "minimum": 0.01, "maximum": 588 } ] }, { "description": "IMPLANT BRICKYARD SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1184, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 562.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 532.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 592 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 532.8 } ], "minimum": 0.01, "maximum": 592 } ] }, { "description": "SCREW LOCKING 2.5 8-34MM MEDARTIS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 545.4, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 259.07, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 245.43 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 272.7 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 245.43 } ], "minimum": 0.01, "maximum": 272.7 } ] }, { "description": "IMPLANT SCREW 3.5MM LOCKING MEDLINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 640, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 304, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 288 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 320 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 288 } ], "minimum": 0.01, "maximum": 320 } ] }, { "description": "IMPLANT 2.7 SCREW LOCKING 2021 ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 449.44, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 213.48, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 202.248 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 224.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 202.248 } ], "minimum": 0.01, "maximum": 224.72 } ] }, { "description": "IMPLANT SCREW 3.5 LOCKING ENOVIS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1260, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 598.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 567 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 630 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 567 } ], "minimum": 0.01, "maximum": 630 } ] }, { "description": "IMPLANT SYMPHONY SYSTEM SET SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 196, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 93.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 88.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 98 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 88.2 } ], "minimum": 0.01, "maximum": 98 } ] }, { "description": "IMPLANT EVEREST SCREW 6.5 STRYKER SPINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2940, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1396.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1323 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1470 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1323 } ], "minimum": 0.01, "maximum": 1470 } ] }, { "description": "IMPLANT EXPEDIUM VERSE SPINE SET SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 200, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 95, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 90 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 100 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 90 } ], "minimum": 0.01, "maximum": 100 } ] }, { "description": "IMPLANT 3 LEVEL CERVICAL PLATE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1489.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT SKY ANTERIOR VAR SD SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 411.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 195.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 185.22 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 205.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 185.22 } ], "minimum": 0.01, "maximum": 205.8 } ] }, { "description": "IMPLANT SET SCREW ACDF/PCF GCSDM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 196, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 93.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 88.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 98 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 88.2 } ], "minimum": 0.01, "maximum": 98 } ] }, { "description": "IMPLANT 3.5MM SYMPHONY POLY SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT 4 LEVEL PLATE VY SPINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1489.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT SET SCREW VY SPINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 196, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 93.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 88.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 98 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 88.2 } ], "minimum": 0.01, "maximum": 98 } ] }, { "description": "IMPLANT VALENCIA MIS SCREW 7.5 ALTUS SPI", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2048.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT TiSCREW 5.0 ORTHOFIX", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1056, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 501.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 475.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 528 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 475.2 } ], "minimum": 0.01, "maximum": 528 } ] }, { "description": "IMPLANT MONACO PEDICLE SCREW 6.5 ALTUS S", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT SCREW 2.7 LOCKING ENOVIS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1260, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 598.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 567 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 630 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 567 } ], "minimum": 0.01, "maximum": 630 } ] }, { "description": "GUIDE WIRE .062 TRILLANT", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 56, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 25.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 28 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.2 } ], "minimum": 0.01, "maximum": 28 } ] }, { "description": "IMPLANT SET SCREW SPINAL ELEMENT", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 196, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 93.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 88.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 98 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 88.2 } ], "minimum": 0.01, "maximum": 98 } ] }, { "description": "IMPLANT i-FACTOR 5 CC PUTTY CERAPEDICS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11200, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5320, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5040 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5600 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5040 } ], "minimum": 0.01, "maximum": 5600 } ] }, { "description": "SCREW NON-LOCKING CORTEX GOLD MEDARTIS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 336.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 159.89, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 151.47 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 168.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 151.47 } ], "minimum": 0.01, "maximum": 168.3 } ] }, { "description": "SCREW LOCKING 2.0 6-30 MM 2020 MEDARTIS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 545.4, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 259.07, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 245.43 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 272.7 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 245.43 } ], "minimum": 0.01, "maximum": 272.7 } ] }, { "description": "IMPLANT 4.35MM SELF DRILL FUJI SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 408, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 193.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 183.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 204 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 183.6 } ], "minimum": 0.01, "maximum": 204 } ] }, { "description": "GUIDE WIRE .045 TRILLANT", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 59.36, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 28.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 26.712 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.68 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.712 } ], "minimum": 0.01, "maximum": 29.68 } ] }, { "description": "IMPLANT ANCHOR KNOTLESS 4.5 ZIMMERBIOMET", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1488, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 706.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 669.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 744 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 669.6 } ], "minimum": 0.01, "maximum": 744 } ] }, { "description": "IMPLANT SKY ANTERIOR LRG-D VAR SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 411.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 195.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 185.22 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 205.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 185.22 } ], "minimum": 0.01, "maximum": 205.8 } ] }, { "description": "IMPLANT 2 LEVEL PLATE CERVICAL VY SPINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1489.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT VALENCIA MIS SCREW 6.5 ALTUS SPI", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2048.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT SCREW 5.0 ALIF 2020 GCDM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 784, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 372.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 352.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 392 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.8 } ], "minimum": 0.01, "maximum": 392 } ] }, { "description": "IMPLANT SCREW 5.5 ALIF 2020 GCDM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 784, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 372.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 352.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 392 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.8 } ], "minimum": 0.01, "maximum": 392 } ] }, { "description": "IMPLANT VERSE SPINE 50MM POLYAXIAL SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3228, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1533.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1452.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1614 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1452.6 } ], "minimum": 0.01, "maximum": 1614 } ] }, { "description": "IMPLANT LOCKING PLATE ASSY PISCES-SA", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 392, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 186.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 176.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 196 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 176.4 } ], "minimum": 0.01, "maximum": 196 } ] }, { "description": "IMPLANT BRICKYARD BLOCKING PLATE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 392, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 186.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 176.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 196 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 176.4 } ], "minimum": 0.01, "maximum": 196 } ] }, { "description": "IMPLANT SCREW 3.5MM NON-LOCKING MEDLINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 500, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 237.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 225 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 250 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 225 } ], "minimum": 0.01, "maximum": 250 } ] }, { "description": "IMPLANT SCREW 2.7MM LOCKING MEDLINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 640, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 304, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 288 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 320 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 288 } ], "minimum": 0.01, "maximum": 320 } ] }, { "description": "IMPLANT VENTANA CERV 6MM INTERBODY", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2048.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT SCREW 4.0MM CERVICAL", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 411.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 195.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 185.22 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 205.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 185.22 } ], "minimum": 0.01, "maximum": 205.8 } ] }, { "description": "IMPLANT EXPEDIUM SYS PRE BENT ROD", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 784, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 372.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 352.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 392 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.8 } ], "minimum": 0.01, "maximum": 392 } ] }, { "description": "IMPLANT LUMIVY IBF 8MM TI PEEK VY SP", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5213.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT VERSE SPINE 45MM POLYAXIAL SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3228, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1533.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1452.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1614 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1452.6 } ], "minimum": 0.01, "maximum": 1614 } ] }, { "description": "PER LOCKING SCREW 3.5 ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 449.44, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 213.48, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 202.248 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 224.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 202.248 } ], "minimum": 0.01, "maximum": 224.72 } ] }, { "description": "IMPLANT SCREW 3.5 NON LOCKING ENOVIS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 760, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 361, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 342 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 380 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 342 } ], "minimum": 0.01, "maximum": 380 } ] }, { "description": "IMPLANT 5 LEVEL PLATE VY SPINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1489.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT TIGER CANNULATED 3.0 SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 740, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 351.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 333 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 370 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 333 } ], "minimum": 0.01, "maximum": 370 } ] }, { "description": "BIOCOMPOSITE SWIVELOCK ANCHOR 4.75 ARTH", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1680, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 798, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 756 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 840 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 756 } ], "minimum": 0.01, "maximum": 840 } ] }, { "description": "ZIPTIGHT ANKLE SYN SYSTEM-SS ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4844, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2300.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2179.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2422 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2179.8 } ], "minimum": 0.01, "maximum": 2422 } ] }, { "description": "IMPLANT SET SCREW LUMBAR", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 196, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 93.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 88.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 98 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 88.2 } ], "minimum": 0.01, "maximum": 98 } ] }, { "description": "IMPLANT 6.5MM PED SCREW LUMBAR OSSEUS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT CERVICAL-TI 6MM INTERBODY PEEK S", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2048.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT VALENCIA MIS SCREW 8.5 ALTUS SPI", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2048.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "K-WIRE 2.0mm (.078) ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 44.88, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.32, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 20.196 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.44 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.196 } ], "minimum": 0.01, "maximum": 22.44 } ] }, { "description": "SCREW VASD ATLANTIS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 411.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 195.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 185.22 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 205.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 185.22 } ], "minimum": 0.01, "maximum": 205.8 } ] }, { "description": "IMPLANT SCREW VARIABLE SD 14MM SMS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 411.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 195.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 185.22 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 205.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 185.22 } ], "minimum": 0.01, "maximum": 205.8 } ] }, { "description": "IMPLANT MAXBRAID #2 ,O-6 ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 364, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 172.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 163.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 182 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 163.8 } ], "minimum": 0.01, "maximum": 182 } ] }, { "description": "IMPLANT PARTIAL THREAD OLIVE WIRE ENOVIS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 180, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 85.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 81 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 90 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 81 } ], "minimum": 0.01, "maximum": 90 } ] }, { "description": "FIBERGRAFT GB PUTTY XXS 1cc DEPUY SPINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1300, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 617.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 585 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 650 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 585 } ], "minimum": 0.01, "maximum": 650 } ] }, { "description": "IMPLANT ANCHOR CABLE ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1573.08, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 747.21, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 707.886 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 786.54 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 707.886 } ], "minimum": 0.01, "maximum": 786.54 } ] }, { "description": "GUIDEWIRE 3.2 ORTHOFIX", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 809.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.56, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 364.32 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 404.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 364.32 } ], "minimum": 0.01, "maximum": 404.8 } ] }, { "description": "IMPLANT POLYAXIAL SCREW 3.5MM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "SCREW CORTEX 3.5MM SYNTHES 12MM-20MM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 424, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 201.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 190.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 212 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 190.8 } ], "minimum": 0.01, "maximum": 212 } ] }, { "description": "IMPLANT 3 LEVEL PLATE ZAVATION", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1489.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT SET SCREW ACDF/PCF GCSDM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 196, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 93.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 88.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 98 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 88.2 } ], "minimum": 0.01, "maximum": 98 } ] }, { "description": "IMPLANT 4.5 SELF TAPPING VARIABLE SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 411.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 195.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 185.22 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 205.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 185.22 } ], "minimum": 0.01, "maximum": 205.8 } ] }, { "description": "IMPLANT SCREW 2.8MM LOCKING 2020 MEDARTI", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 545.4, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 259.07, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 245.43 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 272.7 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 245.43 } ], "minimum": 0.01, "maximum": 272.7 } ] }, { "description": "CANNULATED SCREW 1/2 THREAD 4.0 ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 799.04, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.54, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 359.568 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 399.52 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 359.568 } ], "minimum": 0.01, "maximum": 399.52 } ] }, { "description": "IMPLANT PEDICLE SCREW 8.5MM VY SPINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT 4 LEVEL PLATE ZAVATION", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1489.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT VIPER SYS INNER SET SCREW J&J", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 200, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 95, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 90 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 100 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 90 } ], "minimum": 0.01, "maximum": 100 } ] }, { "description": "COMPRESSION STAPLE 2023 SYSTEM 20MM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7392, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3511.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3326.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3696 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3326.4 } ], "minimum": 0.01, "maximum": 3696 } ] }, { "description": "IMPLANT VERSE SPINE 35MM POLYAXIAL SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3228, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1533.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1452.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1614 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1452.6 } ], "minimum": 0.01, "maximum": 1614 } ] }, { "description": "IMPLANT TiCALC 5MM THRD HEAD SCREW ORT", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1321.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 627.76, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 594.72 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 660.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 594.72 } ], "minimum": 0.01, "maximum": 660.8 } ] }, { "description": "IMPLANT 4.5 CANNULATED TRIMMABLE NAIL", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7780, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3695.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3501 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3890 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3501 } ], "minimum": 0.01, "maximum": 3890 } ] }, { "description": "IMPLANT TIGER CANN HEADLESS 3.0 SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1240, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 589, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 558 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 620 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 558 } ], "minimum": 0.01, "maximum": 620 } ] }, { "description": "IMPLANT IFUSE GRANITE SYSTEM SI-BONE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6650, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6300 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6300 } ], "minimum": 0.01, "maximum": 7000 } ] }, { "description": "IMPLANT SCREW VIPER X-TAB 7.0MM J&J", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3800, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1805, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1710 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1900 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1710 } ], "minimum": 0.01, "maximum": 1900 } ] }, { "description": "IMPLANT Z-SPAN LUMBAR PLATE 20MM ZAVATIO", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5213.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT Z-SPAN LUMBAR PLATE 22MM ZAVATIO", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5213.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT 3.5MM SYMPHONY POLY SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT LOCKING END CAP ORTHOFIX", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1056, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 501.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 475.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 528 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 475.2 } ], "minimum": 0.01, "maximum": 528 } ] }, { "description": "IMPLANT 2.9MM ANCHOR QUATTRO ZIMMERBIOM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1400, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 665, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 630 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 700 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 630 } ], "minimum": 0.01, "maximum": 700 } ] }, { "description": "IMPLANT YUKON PCF SCREW 3.5 STRYKER SPIN", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2800, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1330, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1260 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1400 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1260 } ], "minimum": 0.01, "maximum": 1400 } ] }, { "description": "IMPLANT 4.5MM SCREW ACDF 2020 GCSDM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 411.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 195.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 185.22 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 205.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 185.22 } ], "minimum": 0.01, "maximum": 205.8 } ] }, { "description": "IMPLANT PLATE 8-HOLE 2.7MM 2021 ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 674.16, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 320.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 303.372 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 337.08 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 303.372 } ], "minimum": 0.01, "maximum": 337.08 } ] }, { "description": "IMPLANT 2.5 HAMMERTOE FIXATION SYS OSSIO", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5980, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2840.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2691 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2990 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2691 } ], "minimum": 0.01, "maximum": 2990 } ] }, { "description": "IMPLANT KESTREL SCREW INNOVASIS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 784, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 372.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 352.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 392 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.8 } ], "minimum": 0.01, "maximum": 392 } ] }, { "description": "IMPLANT KESTREL TI PLATE SMALL", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3920, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1862, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1764 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1960 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1764 } ], "minimum": 0.01, "maximum": 1960 } ] }, { "description": "IMPLANT LUMBAR PLATE 23MM GCSDM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5213.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "SUTURE ANCHOR SWIVELOCK TENDOE PEEK", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1827, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 867.83, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 822.15 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 913.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 822.15 } ], "minimum": 0.01, "maximum": 913.5 } ] }, { "description": "IMPLANT SCREW 4.0MM LOCKING MEDLINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 640, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 304, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 288 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 320 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 288 } ], "minimum": 0.01, "maximum": 320 } ] }, { "description": "IMPLANT CANCELLOUS SELF-TAPPING 6.5MM MI", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 200, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 95, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 90 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 100 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 90 } ], "minimum": 0.01, "maximum": 100 } ] }, { "description": "IMPLANT 5.5 CANNULATED TRIMMABLE NAIL", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7780, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3695.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3501 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3890 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3501 } ], "minimum": 0.01, "maximum": 3890 } ] }, { "description": "IMPLANT 9.5 POLY PEDICLE SCREW ALTUS SPI", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT STD MTP PLATE ENOVIS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9620, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4569.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4329 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4810 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4329 } ], "minimum": 0.01, "maximum": 4810 } ] }, { "description": "IMPLANT SCREW 3.5 LOCKING LOW PROFILE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 483, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 229.43, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 217.35 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 241.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 217.35 } ], "minimum": 0.01, "maximum": 241.5 } ] }, { "description": "IMPLANT VENTANA CERV 7MM INTERBODY", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2048.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "K-WIRE 2.0 ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 342.72, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 162.79, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 154.224 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 171.36 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 154.224 } ], "minimum": 0.01, "maximum": 171.36 } ] }, { "description": "GUIDEWIRE 3.2 ORTHOFIX", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 684, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 324.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 307.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 342 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 307.8 } ], "minimum": 0.01, "maximum": 342 } ] }, { "description": "IMPLANT SCREW 2.7 LOCKING LOW PROFILE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 483, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 229.43, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 217.35 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 241.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 217.35 } ], "minimum": 0.01, "maximum": 241.5 } ] }, { "description": "IMPLANT SCREW 2.7 NON LOCKING ENOVIS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 760, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 361, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 342 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 380 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 342 } ], "minimum": 0.01, "maximum": 380 } ] }, { "description": "IMPLANT PLATE CERVICAL 2 LEVEL 2020 GCSD", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1489.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT 4 LEVEL CERVICAL PLATE 2020 GCSD", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1489.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT SET SCREW LUMBAR 2020 GCSDM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 196, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 93.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 88.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 98 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 88.2 } ], "minimum": 0.01, "maximum": 98 } ] }, { "description": "K-WIRE 1.1mm (.045) ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 32.64, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 15.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 14.688 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.32 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.688 } ], "minimum": 0.01, "maximum": 16.32 } ] }, { "description": "IMPLANT FLAREHAWK SHORT SHELL INTEGRITY", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3800, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3600 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3600 } ], "minimum": 0.01, "maximum": 4000 } ] }, { "description": "IMPLANT VARIABLE SCREW 4.0 AURORA", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 411.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 195.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 185.22 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 205.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 185.22 } ], "minimum": 0.01, "maximum": 205.8 } ] }, { "description": "IMPLANT SCREW 2.0 SNAP OFF MEDLINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 780, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 370.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 351 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 390 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 351 } ], "minimum": 0.01, "maximum": 390 } ] }, { "description": "IMPLANT 3.0MM SCREW CANNULATED MEDLINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 600, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 285, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 270 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 300 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 270 } ], "minimum": 0.01, "maximum": 300 } ] }, { "description": "IMPLANT MAXBRAID #5 ,O-6 ZIMMERBIOM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 364, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 172.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 163.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 182 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 163.8 } ], "minimum": 0.01, "maximum": 182 } ] }, { "description": "IMPLANT CANNULATED SCREW 3.0 LONG THREAD", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2132, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1012.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 959.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1066 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 959.4 } ], "minimum": 0.01, "maximum": 1066 } ] }, { "description": "IMPLANT INVICTUS SET SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 196, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 93.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 88.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 98 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 88.2 } ], "minimum": 0.01, "maximum": 98 } ] }, { "description": "IMPLANT SCREW 9.5MM REDUCTION ALPHATEC", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3234, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1536.15, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1455.3 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1617 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1455.3 } ], "minimum": 0.01, "maximum": 1617 } ] }, { "description": "IMPLANT 3 LEVEL PLATE ZAVATION", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1489.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT SKY ANT CERV 2 LVL PLATE SYS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1489.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT 4.0 SELF TAPPING VARIABLE SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 411.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 195.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 185.22 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 205.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 185.22 } ], "minimum": 0.01, "maximum": 205.8 } ] }, { "description": "IMPLANT 6.5MM SPINAL BONE SCREW INNOVASI", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT SET SCREW INNOVASIS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 196, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 93.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 88.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 98 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 88.2 } ], "minimum": 0.01, "maximum": 98 } ] }, { "description": "IMPLANT UNIVERSAL HALF PIN BOLT FIXATIO", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1400, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 665, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 630 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 700 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 630 } ], "minimum": 0.01, "maximum": 700 } ] }, { "description": "IMPLANT 5.0MM SELF DRILLING VAR SCREW PR", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 784, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 372.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 352.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 392 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.8 } ], "minimum": 0.01, "maximum": 392 } ] }, { "description": "IMPLANT 5.5MM SELF DRILLING VAR SCREW PR", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 784, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 372.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 352.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 392 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.8 } ], "minimum": 0.01, "maximum": 392 } ] }, { "description": "K-WIRE 1.6 75MM OLIVE 20-25MM MEDARTIS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 373.8, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 177.56, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 168.21 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 186.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 168.21 } ], "minimum": 0.01, "maximum": 186.9 } ] }, { "description": "IMPLANT TOV 9MM TI GOLD VILEX", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3800, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3600 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3600 } ], "minimum": 0.01, "maximum": 4000 } ] }, { "description": "IMPLANT TOV 8MM TI D.BLUE VILEX", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3800, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3600 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3600 } ], "minimum": 0.01, "maximum": 4000 } ] }, { "description": "IMPLANT SCREW 2.7MM CORTICAL ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 99.88, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 47.44, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 44.946 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 49.94 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 44.946 } ], "minimum": 0.01, "maximum": 49.94 } ] }, { "description": "IMPLANT COUNTERSINK 3.0/4.0 ENOVIS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1048, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 497.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 471.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 524 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 471.6 } ], "minimum": 0.01, "maximum": 524 } ] }, { "description": "IMPLANT 6.5MM SCREW CANNULATED ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 948.84, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 450.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 426.978 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 474.42 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 426.978 } ], "minimum": 0.01, "maximum": 474.42 } ] }, { "description": "IMPLANT 3.5 CORTICAL SCREW SELF TAP ZIMM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 124.84, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 59.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 56.178 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 62.42 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 56.178 } ], "minimum": 0.01, "maximum": 62.42 } ] }, { "description": "CORRECTION PLATE NARROW RADIUS 2.5MM RT", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4108.48, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1951.53, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1848.816 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2054.24 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1848.816 } ], "minimum": 0.01, "maximum": 2054.24 } ] }, { "description": "SUTURE #2 PE 1/2 CIRCLE 38 ZIMMERBIOM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 47.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 45 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 50 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 45 } ], "minimum": 0.01, "maximum": 50 } ] }, { "description": "TiTAN ANKLE HINDFOOT NAIL10MM ORTHOFIX", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12848, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6102.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5781.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6424 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5781.6 } ], "minimum": 0.01, "maximum": 6424 } ] }, { "description": "IMPLANT WASHER FOR CANNULATED SCREW ZIMM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 174.8, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 83.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 78.66 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 87.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 78.66 } ], "minimum": 0.01, "maximum": 87.4 } ] }, { "description": "IMPLANT DYNANAIL TTC FUSION NAIL", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 40000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 19000, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 18000 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 20000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 18000 } ], "minimum": 0.01, "maximum": 20000 } ] }, { "description": "IMPLANT SCREW 4.0MM CANNULATED ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 799.04, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.54, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 359.568 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 399.52 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 359.568 } ], "minimum": 0.01, "maximum": 399.52 } ] }, { "description": "IMPLANT HAMMERTOE FIXATION SYS 2.9 OSSIO", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5980, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2840.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2691 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2990 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2691 } ], "minimum": 0.01, "maximum": 2990 } ] }, { "description": "IMPLANT NAIL 11/200 ORTHOFIX", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12848, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6102.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5781.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6424 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5781.6 } ], "minimum": 0.01, "maximum": 6424 } ] }, { "description": "IMPLANT 3 LEVEL CERVICAL FUSION PLATE AL", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1489.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT X-LINK 35MM PCF GCSDM/VY SP", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3332, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1582.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1499.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1666 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1499.4 } ], "minimum": 0.01, "maximum": 1666 } ] }, { "description": "IMPLANT 2.5 HAMMERTOE FIXATION OSSIO", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5180, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2460.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2331 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2590 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2331 } ], "minimum": 0.01, "maximum": 2590 } ] }, { "description": "IMPLANT HAMMERTOE FIXATION SYS 2.9 OSSIO", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5980, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2840.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2691 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2990 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2691 } ], "minimum": 0.01, "maximum": 2990 } ] }, { "description": "COMPRESSION STAPLE SYSTEM 11MM OSSIO", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6980, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3315.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3141 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3490 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3141 } ], "minimum": 0.01, "maximum": 3490 } ] }, { "description": "IMPLANT SKY ANT CERV 1 LVL PLATE SYS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1489.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT LONG MTP PLATE RIGHT ENOVIS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9620, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4569.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4329 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4810 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4329 } ], "minimum": 0.01, "maximum": 4810 } ] }, { "description": "ANCHOR PEEK KNOTLESS 4.5 MEDLINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1580, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 750.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 711 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 790 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 711 } ], "minimum": 0.01, "maximum": 790 } ] }, { "description": "IMPLANT Z-SPAN LUMBAR PLATE 18MM ZAVATIO", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5213.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT Z-SPAN LUMBAR PLATE 24MM ZAVATIO", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5213.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT 4.0 TI CANN COMPR HDLESS LT46MM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4380, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2080.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1971 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2190 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1971 } ], "minimum": 0.01, "maximum": 2190 } ] }, { "description": "CANNULATED DRIVER 2.0/2.4", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1048, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 497.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 471.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 524 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 471.6 } ], "minimum": 0.01, "maximum": 524 } ] }, { "description": "IMPLANT 4.35MM CC SELF DRILL FUJI SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 408, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 193.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 183.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 204 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 183.6 } ], "minimum": 0.01, "maximum": 204 } ] }, { "description": "IMPLANT CONDUIT LAT SYS ONE HOLE PLATE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5213.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT 1 LEVEL PLATE ACDF SMS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1489.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT PLATE 6 HOLE MEDARTIS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3535.2, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1679.22, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1590.84 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1767.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1590.84 } ], "minimum": 0.01, "maximum": 1767.6 } ] }, { "description": "IMPLANT SCREW 3.0 TRILLANT", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 700, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 332.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 315 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 350 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 315 } ], "minimum": 0.01, "maximum": 350 } ] }, { "description": "IMPLANT COUNTERSINK 3.0/4.0 TRILLANT", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1060, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 503.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 477 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 530 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 477 } ], "minimum": 0.01, "maximum": 530 } ] }, { "description": "IMPLANT SCREW 2.8 CORTEX BONE MEDARTIS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 336.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 159.89, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 151.47 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 168.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 151.47 } ], "minimum": 0.01, "maximum": 168.3 } ] }, { "description": "IMPLANT SCREW 2.7MM LOCKING MEDLINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 640, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 304, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 288 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 320 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 288 } ], "minimum": 0.01, "maximum": 320 } ] }, { "description": "IMPLANT QUATTRO LINK ANCHOR ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1488, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 706.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 669.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 744 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 669.6 } ], "minimum": 0.01, "maximum": 744 } ] }, { "description": "IMPLANT 2.9MM TOGGLELOC ANCHOR ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2268, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1077.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1020.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1134 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1020.6 } ], "minimum": 0.01, "maximum": 1134 } ] }, { "description": "GUIDE WIRE .035 TRILLANT", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 56, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 25.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 28 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.2 } ], "minimum": 0.01, "maximum": 28 } ] }, { "description": "IMPLANT BROADBAND LOOP ZIMMERBIOM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 392, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 186.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 176.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 196 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 176.4 } ], "minimum": 0.01, "maximum": 196 } ] }, { "description": "GUIDE WIRE 1.8 X ORTHOFIX", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 528, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 250.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 237.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 264 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 237.6 } ], "minimum": 0.01, "maximum": 264 } ] }, { "description": "IMPLANT 1 LEVEL PLATE ZAVATION", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1489.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT 5.5 MM SCREW LUMBAR VY SPINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT FT BEAM 6.5", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5508, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2616.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2478.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2754 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2478.6 } ], "minimum": 0.01, "maximum": 2754 } ] }, { "description": "IMPLANT PLATE 2 LEVEL CERVICAL", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1489.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT FIXED SCREW 4.0 AURORA", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 411.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 195.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 185.22 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 205.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 185.22 } ], "minimum": 0.01, "maximum": 205.8 } ] }, { "description": "IMPLANT LUMBAR PLATE BONE SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2352, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1117.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1058.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1176 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1058.4 } ], "minimum": 0.01, "maximum": 1176 } ] }, { "description": "IMPLANT BOWLINE 2.5CC DBM PUTTY TIDES", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1264, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 600.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 568.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 632 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 568.8 } ], "minimum": 0.01, "maximum": 632 } ] }, { "description": "IMPLANT COUNTERSINK 3.0 / 3.5 MEDLINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 700, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 332.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 315 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 350 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 315 } ], "minimum": 0.01, "maximum": 350 } ] }, { "description": "IMPLANT 4.75 ANCHOR W/SNARE OSSIO", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1980, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 940.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 891 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 990 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 891 } ], "minimum": 0.01, "maximum": 990 } ] }, { "description": "IMPLANT 4.0 COMPRESSION STAPLE OSSIO", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5392, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2561.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2426.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2696 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2426.4 } ], "minimum": 0.01, "maximum": 2696 } ] }, { "description": "KYPHON BONE CEMENT XPHON MIXER PACK", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 988.92, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 469.74, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 445.014 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 494.46 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 445.014 } ], "minimum": 0.01, "maximum": 494.46 } ] }, { "description": "IMPLANT 4.0 CANNULATED TRIMMABLE NAIL", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6340, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3011.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2853 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3170 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2853 } ], "minimum": 0.01, "maximum": 3170 } ] }, { "description": "IMPLANT CANNULATED SCREW 3.0 SHORT THRED", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2132, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1012.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 959.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1066 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 959.4 } ], "minimum": 0.01, "maximum": 1066 } ] }, { "description": "IMPLANT SCREW 6.5MM CANNULATED HEADLESS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2700, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1282.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1215 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1350 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1215 } ], "minimum": 0.01, "maximum": 1350 } ] }, { "description": "IMPLANT 5.0MM SYMPHONY POLY SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3400, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1615, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1530 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1700 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1530 } ], "minimum": 0.01, "maximum": 1700 } ] }, { "description": "IMPLANT DEXA-C 14MM X 7 CAGE ACDF AURORA", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2048.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT 4.0MM SCREW CANNULATED MEDLINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 700, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 332.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 315 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 350 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 315 } ], "minimum": 0.01, "maximum": 350 } ] }, { "description": "IMPLANT PLATE TN FUSION LARGE MEDLINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7200, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3420, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3240 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3600 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3240 } ], "minimum": 0.01, "maximum": 3600 } ] }, { "description": "IMPLANT SYSTEM MPFL FASTTHREAD ARTHREX", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8379, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3980.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3770.55 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4189.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3770.55 } ], "minimum": 0.01, "maximum": 4189.5 } ] }, { "description": "COMPRESSION STAPLE SYSTEM 09MM OSSIO", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6980, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3315.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3141 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3490 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3141 } ], "minimum": 0.01, "maximum": 3490 } ] }, { "description": "KNOTLESS 3.0MM SUTURETAK ANCHOR ARTHREX", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2205, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1047.38, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 992.25 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1102.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 992.25 } ], "minimum": 0.01, "maximum": 1102.5 } ] }, { "description": "IMPLANT LATERAL FIBULA, SMALL RIGHT MEDL", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3180, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1510.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1431 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1590 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1431 } ], "minimum": 0.01, "maximum": 1590 } ] }, { "description": "MPJ PETITE MTP PLATE LEFT ENOVIS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9620, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4569.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4329 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4810 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4329 } ], "minimum": 0.01, "maximum": 4810 } ] }, { "description": "IMPLANT PILOT DRILL 3.0/4.0 ENOVIS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 475, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 450 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 450 } ], "minimum": 0.01, "maximum": 500 } ] }, { "description": "IMPLANT TiCALC 5X60MM THRD HEAD SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1321.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 627.76, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 594.72 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 660.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 594.72 } ], "minimum": 0.01, "maximum": 660.8 } ] }, { "description": "IMPLANT VALENCIA MIS SCREW 5.5 ALTUS SPI", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2048.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT ENOFIX W/ CONSTRICTOR FIXATION", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6720, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3192, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3024 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3360 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3024 } ], "minimum": 0.01, "maximum": 3360 } ] }, { "description": "GUIDE WIRE OLIVE .062 X 3 TRILLANT", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 180, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 85.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 81 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 90 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 81 } ], "minimum": 0.01, "maximum": 90 } ] }, { "description": "IMPLANT 3.7MM TI CERVICAL SPINE SLF DRIL", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 588, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 279.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 264.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 294 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 264.6 } ], "minimum": 0.01, "maximum": 294 } ] }, { "description": "IMPLANT MONACO PEDICLE SCREW 5.5 ALTUS S", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT TRIM-IT DRILL PIN 1.5MM ARTHREX", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1470, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 698.25, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 661.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 735 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 661.5 } ], "minimum": 0.01, "maximum": 735 } ] }, { "description": "IMPLANT EVANS BIOIMPLANT 10-12MM PRE HY", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7800, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3705, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3510 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3900 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3510 } ], "minimum": 0.01, "maximum": 3900 } ] }, { "description": "IMPLANT SCREW 4.0MM NON-LOCKING MEDLINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 500, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 237.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 225 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 250 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 225 } ], "minimum": 0.01, "maximum": 250 } ] }, { "description": "IMPLANT ALIF PLATE 21-27MM FOR L4-L5 PRE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5213.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "BIO COMPOSITE PUSHLOCK KIT ARTHREX", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 924, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 438.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 415.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 462 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 415.8 } ], "minimum": 0.01, "maximum": 462 } ] }, { "description": "IMPLANT SUTURETAPE TIGERLINK ARTHREX", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 357, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 169.58, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 160.65 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 178.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 160.65 } ], "minimum": 0.01, "maximum": 178.5 } ] }, { "description": "IMPLANT GRAFTON PLUS DBM PUTTY 1CC", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 864, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 410.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 388.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 432 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 388.8 } ], "minimum": 0.01, "maximum": 432 } ] }, { "description": "IMPLANT AERIAL FIXATION SYS 8X22 7-13MM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15680, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 7448, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7056 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7840 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7056 } ], "minimum": 0.01, "maximum": 7840 } ] }, { "description": "SUTURE ANCHOR MINI BC PUSHLOCK ARTHREX", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1785, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 847.88, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 803.25 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 892.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 803.25 } ], "minimum": 0.01, "maximum": 892.5 } ] }, { "description": "IMPLANT TOV 7MM TI L.BLUE VILEX", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3800, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3600 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3600 } ], "minimum": 0.01, "maximum": 4000 } ] }, { "description": "IMPLANT CHI MINI 10_TI GOLD VILEX", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4750, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4500 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4500 } ], "minimum": 0.01, "maximum": 5000 } ] }, { "description": "IMPLANT ARSENAL MPJ-CAP TRILLIANT", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5700, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5400 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5400 } ], "minimum": 0.01, "maximum": 6000 } ] }, { "description": "IMPLANT MONACO PEDICLE SCREW 8.5 ALTUS S", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT TIGER CANNULATED 2.0 SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 740, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 351.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 333 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 370 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 333 } ], "minimum": 0.01, "maximum": 370 } ] }, { "description": "IMPLANT COUNTERSINK 2.0/2.4", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 475, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 450 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 450 } ], "minimum": 0.01, "maximum": 500 } ] }, { "description": "IMPLANT TIGER CANN HEADLESS 2.4 SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1240, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 589, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 558 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 620 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 558 } ], "minimum": 0.01, "maximum": 620 } ] }, { "description": "IMPLANT TOV 10MM TI MAGENTA VILEX", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3800, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3600 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3600 } ], "minimum": 0.01, "maximum": 4000 } ] }, { "description": "IMPLANT CANNULATED SCREW W/DISP SHTH ART", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 483, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 229.43, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 217.35 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 241.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 217.35 } ], "minimum": 0.01, "maximum": 241.5 } ] }, { "description": "IMPLANT VYSPAN X-LINK 3.5MM VY SPINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3332, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1582.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1499.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1666 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1499.4 } ], "minimum": 0.01, "maximum": 1666 } ] }, { "description": "IMPLANT 4.5MM CANNULATED HEAD SCREW MEDL", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 525, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 249.38, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 236.25 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 262.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 236.25 } ], "minimum": 0.01, "maximum": 262.5 } ] }, { "description": "IMPLANT WASHER 4.0/4.5MM SCREW MEDLINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 200, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 95, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 90 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 100 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 90 } ], "minimum": 0.01, "maximum": 100 } ] }, { "description": "IMPLANT 4.1MM LISFRANC SOLID SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3580, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1700.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1611 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1790 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1611 } ], "minimum": 0.01, "maximum": 1790 } ] }, { "description": "DOUBLE ENDED K-WIRE .9mm (.035) ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 32.64, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 15.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 14.688 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.32 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.688 } ], "minimum": 0.01, "maximum": 16.32 } ] }, { "description": "PLATE T-PI 4 HOLE MEDARTIS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2809.48, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1334.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1264.266 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1404.74 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1264.266 } ], "minimum": 0.01, "maximum": 1404.74 } ] }, { "description": "IMPLANT LOCK-STITCH ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 960, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 456, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 432 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 480 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 432 } ], "minimum": 0.01, "maximum": 480 } ] }, { "description": "IMPLANT WASHER 5.5MM - 7.5MM ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 174.8, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 83.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 78.66 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 87.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 78.66 } ], "minimum": 0.01, "maximum": 87.4 } ] }, { "description": "K-WIRE 150MM ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 342.72, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 162.79, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 154.224 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 171.36 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 154.224 } ], "minimum": 0.01, "maximum": 171.36 } ] }, { "description": "IMPLANT SCREW 2.7MM NON-LOCKING MEDLINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 500, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 237.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 225 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 250 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 225 } ], "minimum": 0.01, "maximum": 250 } ] }, { "description": "SCREW LOCKING SELF TAPPING 3.5MM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1412, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 670.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 635.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 706 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 635.4 } ], "minimum": 0.01, "maximum": 706 } ] }, { "description": "DRILL AND PIN SET ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 299.64, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 134.838 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 149.82 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 134.838 } ], "minimum": 0.01, "maximum": 149.82 } ] }, { "description": "PLATE DISTAL RADIUS 2.5MM (BABY FOOT)", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4108.48, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1951.53, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1848.816 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2054.24 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1848.816 } ], "minimum": 0.01, "maximum": 2054.24 } ] }, { "description": "IMPLANT PLATE ATLANTIS ELITE MEDTRONIC", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1489.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT 7 HOLE PLATE ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 674.16, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 320.23, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 303.372 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 337.08 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 303.372 } ], "minimum": 0.01, "maximum": 337.08 } ] }, { "description": "IMPLANT WASHER SMALL ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 97.92, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 46.51, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 44.064 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 48.96 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 44.064 } ], "minimum": 0.01, "maximum": 48.96 } ] }, { "description": "IMPLANT SCREW 10.0 X MM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2450, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1163.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1102.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1225 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1102.5 } ], "minimum": 0.01, "maximum": 1225 } ] }, { "description": "IMPLANT PLATE 4 HOLE ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 563.04, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 267.44, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 253.368 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 281.52 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 253.368 } ], "minimum": 0.01, "maximum": 281.52 } ] }, { "description": "IMPLANT 8 HOLE PLATE ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1373.32, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 652.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 617.994 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 686.66 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 617.994 } ], "minimum": 0.01, "maximum": 686.66 } ] }, { "description": "IMPLANT SCREW 3.5 CORTEX LOW PROFILE ART", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 147, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 69.83, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 66.15 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 73.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 66.15 } ], "minimum": 0.01, "maximum": 73.5 } ] }, { "description": "IMPLANT PLATE DISTAL FIBULA 8H RT ARTHRE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3339, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1586.03, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1502.55 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1669.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1502.55 } ], "minimum": 0.01, "maximum": 1669.5 } ] }, { "description": "IMPLANT CAGE LUMBAR SIZE 11 PRECISION SP", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9832, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4670.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4424.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4916 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4424.4 } ], "minimum": 0.01, "maximum": 4916 } ] }, { "description": "IMPLANT SCREW 7X14 QUATTRO BOLT ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1380, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 655.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 621 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 690 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 621 } ], "minimum": 0.01, "maximum": 690 } ] }, { "description": "IMPLANT SUBTALAR 10MM DISCO TRILLIANT", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4800, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2280, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2160 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2400 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2160 } ], "minimum": 0.01, "maximum": 2400 } ] }, { "description": "SUTURE ANCHOR SWIVELOCK TENDOESIS 7MM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1827, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 867.83, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 822.15 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 913.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 822.15 } ], "minimum": 0.01, "maximum": 913.5 } ] }, { "description": "IMPLANT SCREW 6X12 QUATTRO BOLT ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1380, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 655.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 621 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 690 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 621 } ], "minimum": 0.01, "maximum": 690 } ] }, { "description": "PLATE DISTAL RADIUS 2.5MM NARROW LT PI", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4108.48, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1951.53, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1848.816 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2054.24 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1848.816 } ], "minimum": 0.01, "maximum": 2054.24 } ] }, { "description": "PLATE DISTAL RADIUS VOLAR (BABY FOOT)", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4108.48, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1951.53, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1848.816 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2054.24 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1848.816 } ], "minimum": 0.01, "maximum": 2054.24 } ] }, { "description": "IMPLANT TiCALC SCREW ORTHOFIX", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1061.56, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 504.24, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 477.702 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 530.78 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 477.702 } ], "minimum": 0.01, "maximum": 530.78 } ] }, { "description": "IMPLANT AX ALIF PLATE SMALL INNOVASIS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 392, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 186.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 176.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 196 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 176.4 } ], "minimum": 0.01, "maximum": 196 } ] }, { "description": "TRANSTIBIAL KIT W/ SAWBLD ARTHREX", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 945, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 448.88, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 425.25 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 472.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 425.25 } ], "minimum": 0.01, "maximum": 472.5 } ] }, { "description": "IMPLANT PERIARTICULAR SCREW 6.5 ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 199.76, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.89, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 89.892 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 99.88 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 89.892 } ], "minimum": 0.01, "maximum": 99.88 } ] }, { "description": "IMPLANT SACRAL PLATE GCDM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5213.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT 10.0MM SCREW LUMBAR GCSDM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT EVEREST SCREW 7.5 STRYKER SPINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2940, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1396.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1323 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1470 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1323 } ], "minimum": 0.01, "maximum": 1470 } ] }, { "description": "ARTHROTOME SMALL JOINT MEDLINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 475, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 450 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 450 } ], "minimum": 0.01, "maximum": 500 } ] }, { "description": "IMPLANT 4.75X19.1 ANCHOR 2020 ARTHREX", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3045, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1446.38, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1370.25 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1522.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1370.25 } ], "minimum": 0.01, "maximum": 1522.5 } ] }, { "description": "SUTURE ANCHOR SWIVELOCK TENDOESIS 6.25", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1722, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 817.95, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 774.9 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 861 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 774.9 } ], "minimum": 0.01, "maximum": 861 } ] }, { "description": "SECNDRY FIXATION 4.75 W BIO SWIVELOCK", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3045, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1446.38, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1370.25 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1522.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1370.25 } ], "minimum": 0.01, "maximum": 1522.5 } ] }, { "description": "IMPLANT X-LINK 90MM LUMBAR VY SPINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3332, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1582.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1499.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1666 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1499.4 } ], "minimum": 0.01, "maximum": 1666 } ] }, { "description": "IMPLANT LORDOTIC SHELL INTEGRITY IMPLANT", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3800, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3600 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3600 } ], "minimum": 0.01, "maximum": 4000 } ] }, { "description": "IMPLANT SCREW 2.0MM CANNULATED MEDLINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 600, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 285, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 270 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 300 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 270 } ], "minimum": 0.01, "maximum": 300 } ] }, { "description": "IMPLANT HAMMERTOE FIXATION SYS 3.2 OSSIO", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5980, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2840.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2691 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2990 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2691 } ], "minimum": 0.01, "maximum": 2990 } ] }, { "description": "IMPLANT PLATE 2LVL AURORA SPINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1489.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT WASHER LARGE ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 149.8, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 71.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 67.41 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 74.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 67.41 } ], "minimum": 0.01, "maximum": 74.9 } ] }, { "description": "IMPLANT SCREW 4.5MM CANNULATED HEADLESS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1100, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 522.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 495 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 550 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 495 } ], "minimum": 0.01, "maximum": 550 } ] }, { "description": "IMPLANT MTP FUSION PLATE MED LEFT MEDLIN", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4800, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2280, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2160 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2400 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2160 } ], "minimum": 0.01, "maximum": 2400 } ] }, { "description": "LAPIPLASTY SYSTEM 1 TREACE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15980, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 7590.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7191 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7990 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7191 } ], "minimum": 0.01, "maximum": 7990 } ] }, { "description": "IMPLANT SUTURETAPE FIBERLOOP W/NDL", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 294, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 139.65, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 132.3 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 147 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 132.3 } ], "minimum": 0.01, "maximum": 147 } ] }, { "description": "IMPLANT TIBIAL LOCKING BAR ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 599.28, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 284.66, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 269.676 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 299.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 269.676 } ], "minimum": 0.01, "maximum": 299.64 } ] }, { "description": "COMPRESSION STAPLE SYSTEM 20MM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3780, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1795.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1701 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1890 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1701 } ], "minimum": 0.01, "maximum": 1890 } ] }, { "description": "IMPLANT 4.0MM SYMPHONY POLY SCREW", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "HEALIX ADVANCE ANCHOR W/DYNATAPE BLK/WHT", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2511.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1193.01, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1130.22 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1255.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1130.22 } ], "minimum": 0.01, "maximum": 1255.8 } ] }, { "description": "HEALIX ADVANCE ANCHOR W/DYNATAPE BLK/WHT", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2511.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1193.01, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1130.22 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1255.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1130.22 } ], "minimum": 0.01, "maximum": 1255.8 } ] }, { "description": "IMPLANT LUMBAR PLATE 21MM GCSDM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5213.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT POLYAXIAL SCREW 4.0MM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT LUMBAR PLATE 25MM GCSDM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5213.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT NCB STRT NARROW SHAFT PLATE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2397.08, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1138.61, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1078.686 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1198.54 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1078.686 } ], "minimum": 0.01, "maximum": 1198.54 } ] }, { "description": "IMPLANT OSSIO 4.75X2 SUTURE ANCHOR SYSTE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4900, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2327.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2205 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2450 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2205 } ], "minimum": 0.01, "maximum": 2450 } ] }, { "description": "COMPRESSION STAPLE 2023 SYSTEM 15MM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6992, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3321.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3146.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3496 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3146.4 } ], "minimum": 0.01, "maximum": 3496 } ] }, { "description": "IMPLANT SKYLINE STRAIGHT FIX PIN", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1148, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 545.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 516.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 574 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 516.6 } ], "minimum": 0.01, "maximum": 574 } ] }, { "description": "IMPLANT HORIZON SUBTALAR 8MM BIOPRO", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8200, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3895, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3690 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4100 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3690 } ], "minimum": 0.01, "maximum": 4100 } ] }, { "description": "IMPLANT SCREW 2.3MM CANNULATED HEADLESS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2780, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1320.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1251 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1390 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1251 } ], "minimum": 0.01, "maximum": 1390 } ] }, { "description": "IMPLANT 3.5MM SCREW CANNULATED MEDLINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 600, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 285, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 270 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 300 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 270 } ], "minimum": 0.01, "maximum": 300 } ] }, { "description": "IMPLANT 2.9 HAMMERTOE FIXATION OSSIO", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5180, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2460.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2331 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2590 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2331 } ], "minimum": 0.01, "maximum": 2590 } ] }, { "description": "IMPLANT FIBULINK REPAIR/SS DEPUY", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13412, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6370.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6035.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6706 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6035.4 } ], "minimum": 0.01, "maximum": 6706 } ] }, { "description": "IMPLANT 2 LEVEL PLATE ZAVATION", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1489.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT 1 LEVEL PLATE ZAVATION/GCSDM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1489.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT 4.0 CANNULATED TRIMMABLE NAIL", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6980, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3315.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3141 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3490 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3141 } ], "minimum": 0.01, "maximum": 3490 } ] }, { "description": "CERAMONT 10MM BONE VOID FILLER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10780, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5120.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4851 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5390 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4851 } ], "minimum": 0.01, "maximum": 5390 } ] }, { "description": "IMPLANT 5 LEVEL PLATE ZAVATION/GCSDM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1489.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT MTP FUSION PLATE XSML RIGHT", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4800, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2280, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2160 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2400 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2160 } ], "minimum": 0.01, "maximum": 2400 } ] }, { "description": "IMPLANT 6MM JUGGERLOC SLOTTED REAMER ZIM", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1200, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 570, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 540 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 600 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 540 } ], "minimum": 0.01, "maximum": 600 } ] }, { "description": "IMPLANT SKY ANT CERV 3 LVL PLATE SYS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1489.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT HAMMERTOE FIXATION", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1900, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1800 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1800 } ], "minimum": 0.01, "maximum": 2000 } ] }, { "description": "IMPLANT SCREW 3.0MM CANNULATED HEADLESS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 475, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 450 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 450 } ], "minimum": 0.01, "maximum": 500 } ] }, { "description": "IMPLANT 3.0 TI CANN COMPR HDLESS ST-16", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3824, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1816.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1720.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1912 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1720.8 } ], "minimum": 0.01, "maximum": 1912 } ] }, { "description": "IMPLANT 2.4 HAMMERTOE FIXATION SYS OSSIO", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5980, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2840.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2691 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2990 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2691 } ], "minimum": 0.01, "maximum": 2990 } ] }, { "description": "IMPLANT UTILITY BIOIMPLANT 12MM PRE HYDR", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7800, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3705, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3510 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3900 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3510 } ], "minimum": 0.01, "maximum": 3900 } ] }, { "description": "IMPLANT TMT OFFSET 4 HOLE PLATE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4400, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2090, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1980 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2200 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1980 } ], "minimum": 0.01, "maximum": 2200 } ] }, { "description": "IMPLANT PLATE COTTON OSTEOTOMY MEDLINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4400, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2090, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1980 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2200 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1980 } ], "minimum": 0.01, "maximum": 2200 } ] }, { "description": "IMPLANT TRILOCK FOUR CORNER PLATE MEDART", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4202.08, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1995.99, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1890.936 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2101.04 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1890.936 } ], "minimum": 0.01, "maximum": 2101.04 } ] }, { "description": "IMPLANT LATERAL FIBULA, LARGE RIGHT MEDL", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3180, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1510.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1431 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1590 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1431 } ], "minimum": 0.01, "maximum": 1590 } ] }, { "description": "IMPLANT 1/3 TUBULAR PLATE 8 HOLE W COLLA", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2040, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 969, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 918 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1020 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 918 } ], "minimum": 0.01, "maximum": 1020 } ] }, { "description": "IMPLANT SCREW 2.5MM CANNULATED HEADLESS", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 475, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 450 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 450 } ], "minimum": 0.01, "maximum": 500 } ] }, { "description": "IMPLANT PROCEDURE LARGE STAPLE X2 MEDLIN", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10780, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5120.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4851 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5390 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4851 } ], "minimum": 0.01, "maximum": 5390 } ] }, { "description": "IMPLANT PERIARTICULAR SCREW 4.0 ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.88, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 69.77, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 66.096 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 73.44 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 66.096 } ], "minimum": 0.01, "maximum": 73.44 } ] }, { "description": "IMPLANT MTP FUSION PLATE XSML LEFT", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4800, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2280, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2160 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2400 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2160 } ], "minimum": 0.01, "maximum": 2400 } ] }, { "description": "IMPLANT NCB STRT NARROW SHAFT PLATE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2397.08, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1138.61, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1078.686 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1198.54 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1078.686 } ], "minimum": 0.01, "maximum": 1198.54 } ] }, { "description": "IMPLANT 3.0 TI CANN COMPR HDLESS ST-18", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3824, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1816.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1720.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1912 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1720.8 } ], "minimum": 0.01, "maximum": 1912 } ] }, { "description": "IMPLANT ANKLE 6 HOLE LATERAL PLATE TRILL", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7500, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3562.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3375 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3750 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3375 } ], "minimum": 0.01, "maximum": 3750 } ] }, { "description": "IMPLANT FT BEAM 5.0", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5508, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2616.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2478.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2754 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2478.6 } ], "minimum": 0.01, "maximum": 2754 } ] }, { "description": "IMPLANT SCREW 8.5 ZAVATION", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT PROCEDURE LIGAMENT REPAIR ANCHOR", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12269.92, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5828.21, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5521.464 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6134.96 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5521.464 } ], "minimum": 0.01, "maximum": 6134.96 } ] }, { "description": "IMPLANT HORIZON SUBTALAR 8-10MM BIOPRO", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8200, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3895, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3690 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4100 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3690 } ], "minimum": 0.01, "maximum": 4100 } ] }, { "description": "IMPLANT ULS RECON PLATE 14-HOLE ZIMMER", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1860.48, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 883.73, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 837.216 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 930.24 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 837.216 } ], "minimum": 0.01, "maximum": 930.24 } ] }, { "description": "IMPLANT PROCEDURE 4-LEG STAPLE MEDLINE", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6780, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3220.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3051 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3390 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3051 } ], "minimum": 0.01, "maximum": 3390 } ] }, { "description": "IMPLANT Z-SPAN LUMBAR PLATE 26MM ZAVATIO", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5213.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "FORTIFY ASSURA DR DEFIBRILLATOR ST JUDE", "code_information": [ { "code": "C1721", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 53600, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 25460, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 24120 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 26800 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 24120 } ], "minimum": 0.01, "maximum": 26800 } ] }, { "description": "SPECIMEN TRAP FOR SUCTION CANNISTER", "code_information": [ { "code": "C1725", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.63, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.15, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.9835 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.315 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.9835 } ], "minimum": 0.01, "maximum": 3.315 } ] }, { "description": "BALLOON INFLATION DEVICE ACCLARENT", "code_information": [ { "code": "C1726", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 298.2, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 141.65, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 134.19 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 149.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 134.19 } ], "minimum": 0.01, "maximum": 149.1 } ] }, { "description": "DRAIN PENROSE 1/4 MCK DNO", "code_information": [ { "code": "C1729", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4.45, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.11, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.0025 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.225 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.0025 } ], "minimum": 0.01, "maximum": 2.225 } ] }, { "description": "CATHETER RED RUBBER 16FR 0094160", "code_information": [ { "code": "C1729", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1.64, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.78, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.738 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.82 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.738 } ], "minimum": 0.01, "maximum": 0.82 } ] }, { "description": "DRN PENROSE 1/2 X18 MEDLINE", "code_information": [ { "code": "C1729", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 39.8, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 18.91, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 17.91 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 19.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.91 } ], "minimum": 0.01, "maximum": 19.9 } ] }, { "description": "LATEX DRAIN PENROSE 1/4 MEDLINE", "code_information": [ { "code": "C1729", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5.8, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.76, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.61 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.61 } ], "minimum": 0.01, "maximum": 2.9 } ] }, { "description": "IMPLANT BONALIVE 10CC LG ORTHO GRANULES", "code_information": [ { "code": "C1734", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15480, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4644, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6966 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7740 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6966 } ], "minimum": 0.01, "maximum": 7740 } ] }, { "description": "IMPLANT BONALIVE 5CC LG ORTHO GRANULES", "code_information": [ { "code": "C1734", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10460, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3138, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4707 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5230 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4707 } ], "minimum": 0.01, "maximum": 5230 } ] }, { "description": "IMPLANT BONALIVE 5CC ORTHO GRANULES TRIM", "code_information": [ { "code": "C1734", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10460, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3138, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4707 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5230 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4707 } ], "minimum": 0.01, "maximum": 5230 } ] }, { "description": "IMPLANT BONALIVE 5CC ORTHO GRANULES TRIM", "code_information": [ { "code": "C1734", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10460, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3138, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4707 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5230 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4707 } ], "minimum": 0.01, "maximum": 5230 } ] }, { "description": "IMPLANT BONALIVE 10CC LG ORTHO GRANULES", "code_information": [ { "code": "C1734", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15480, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4644, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6966 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7740 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6966 } ], "minimum": 0.01, "maximum": 7740 } ] }, { "description": "IMPLANT BONALIVE 10CC LG ORTHO GRANULES", "code_information": [ { "code": "C1734", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15480, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4644, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6966 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7740 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6966 } ], "minimum": 0.01, "maximum": 7740 } ] }, { "description": "IMPLANT BONALIVE 10CC LG ORTHO GRANULES", "code_information": [ { "code": "C1734", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15480, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4644, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6966 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7740 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6966 } ], "minimum": 0.01, "maximum": 7740 } ] }, { "description": "IMPLANT BONALIVE 2.5CC ORTHO GRANULES T", "code_information": [ { "code": "C1734", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7720, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2316, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3474 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3860 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3474 } ], "minimum": 0.01, "maximum": 3860 } ] }, { "description": "IMPLANT BONALIVE 2.5CC ORTHO GRANULES T", "code_information": [ { "code": "C1734", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7720, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2316, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3474 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3860 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3474 } ], "minimum": 0.01, "maximum": 3860 } ] }, { "description": "IMPLANT BONALIVE 2.5CC ORTHO GRANULES T", "code_information": [ { "code": "C1734", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7720, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2316, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3474 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3860 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3474 } ], "minimum": 0.01, "maximum": 3860 } ] }, { "description": "IMPLANT BONALIVE 5CC LG ORTHO GRANULES", "code_information": [ { "code": "C1734", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10460, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3138, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4707 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5230 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4707 } ], "minimum": 0.01, "maximum": 5230 } ] }, { "description": "FLEX URETEROSCOPE AXIS II DORNIER", "code_information": [ { "code": "C1747", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12460, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3738, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5607 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6230 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5607 } ], "minimum": 0.01, "maximum": 6230 } ] }, { "description": "PICC LINE CATH DYNAMIC INFUSION", "code_information": [ { "code": "C1751", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1336.72, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 401.016, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 601.524 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 668.36 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 601.524 } ], "minimum": 0.01, "maximum": 668.36 } ] }, { "description": "MULTI-LUMEN CENTRAL LINE KIT 16CM ARROW", "code_information": [ { "code": "C1751", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 530.84, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 159.252, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 238.878 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 265.42 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 238.878 } ], "minimum": 0.01, "maximum": 265.42 } ] }, { "description": "CATH OPEN END URETERAL 5FR X 70", "code_information": [ { "code": "C1758", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 46.04, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.869, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 20.718 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.02 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.718 } ], "minimum": 0.01, "maximum": 23.02 } ] }, { "description": "CATHETER URETERAL CONE TIP 5FR", "code_information": [ { "code": "C1758", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 57.2, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 27.17, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 25.74 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 28.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.74 } ], "minimum": 0.01, "maximum": 28.6 } ] }, { "description": "IMPLANT ALTIS BLADDER SLING 2023", "code_information": [ { "code": "C1762", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6472, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1941.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2912.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3236 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2912.4 } ], "minimum": 0.01, "maximum": 3236 } ] }, { "description": "IMPLANT ALTIS BLADDER SLING", "code_information": [ { "code": "C1762", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6472, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1941.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2912.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3236 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2912.4 } ], "minimum": 0.01, "maximum": 3236 } ] }, { "description": "FIBERGRAFT GB PUTTY XS 2CC DEPUY SPINE", "code_information": [ { "code": "C1763", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2600, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 780, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1170 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1300 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1170 } ], "minimum": 0.01, "maximum": 1300 } ] }, { "description": "FIBERGRAFT AERIDYAN MATRIX 12.5CC", "code_information": [ { "code": "C1763", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13640, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4092, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6138 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6820 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6138 } ], "minimum": 0.01, "maximum": 6820 } ] }, { "description": "ACTIGLASS SYNTHETIC 3.75G BIOACTVE PUTTY", "code_information": [ { "code": "C1763", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2780, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 834, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1251 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1390 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1251 } ], "minimum": 0.01, "maximum": 1390 } ] }, { "description": "FIBERGRAFT AERIDYAN MATRIX 6.25CC", "code_information": [ { "code": "C1763", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7172, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2151.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3227.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3586 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3227.4 } ], "minimum": 0.01, "maximum": 3586 } ] }, { "description": "FIBERGRAFT BG PUTTY 12.5CC LG DEPUY SPI", "code_information": [ { "code": "C1763", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12400, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3720, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5580 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6200 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5580 } ], "minimum": 0.01, "maximum": 6200 } ] }, { "description": "FIBERGRAFT AERIDYAN MATRIX 3CC", "code_information": [ { "code": "C1763", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6075.2, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1822.56, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2733.84 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3037.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2733.84 } ], "minimum": 0.01, "maximum": 3037.6 } ] }, { "description": "ACTIGLASS SYNTHETIC 7.5G BIOACTVE PUTTY", "code_information": [ { "code": "C1763", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5580, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1674, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2511 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2790 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2511 } ], "minimum": 0.01, "maximum": 2790 } ] }, { "description": "FIBERGRAFT GB PUTTY 4CC DEPUY SPINE", "code_information": [ { "code": "C1763", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4992, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1497.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2246.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2496 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2246.4 } ], "minimum": 0.01, "maximum": 2496 } ] }, { "description": "FIBERGRAFT GB PUTTY 6.25CC DEPUY SPINE", "code_information": [ { "code": "C1763", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6520, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1956, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2934 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3260 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2934 } ], "minimum": 0.01, "maximum": 3260 } ] }, { "description": "IMPLANT IPG 97800 305STPX KIT INTERSTIM", "code_information": [ { "code": "C1767", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 40000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 12000, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 18000 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 20000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 18000 } ], "minimum": 0.01, "maximum": 20000 } ] }, { "description": "IMPLANT IPG 97800 INTERSTIM X", "code_information": [ { "code": "C1767", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 40480, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 12144, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 18216 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 20240 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 18216 } ], "minimum": 0.01, "maximum": 20240 } ] }, { "description": "HYBRID GUIDWIRE GLOBAL LASER SOLUTIONS", "code_information": [ { "code": "C1769", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 180, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 85.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 81 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 90 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 81 } ], "minimum": 0.01, "maximum": 90 } ] }, { "description": "MOTION GUIDE WIRE .038 COOK", "code_information": [ { "code": "C1769", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 265.84, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 126.27, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 119.628 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 132.92 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 119.628 } ], "minimum": 0.01, "maximum": 132.92 } ] }, { "description": "HI TORQUE COMMAND GUIDE WIRE 300CM 018", "code_information": [ { "code": "C1769", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 460, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 218.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 207 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 230 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 207 } ], "minimum": 0.01, "maximum": 230 } ] }, { "description": "GUIDEWIRE 1.6MM SMOOTH MEDLINE", "code_information": [ { "code": "C1769", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 80, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 38, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 36 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 40 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 36 } ], "minimum": 0.01, "maximum": 40 } ] }, { "description": "GUIDE WIRE 1.1MM NON-THREADED", "code_information": [ { "code": "C1769", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 300, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 135 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 150 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 135 } ], "minimum": 0.01, "maximum": 150 } ] }, { "description": "GUIDEWIRE 1.1 X 150MM SMOOTH MEDLINE", "code_information": [ { "code": "C1769", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 80, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 38, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 36 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 40 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 36 } ], "minimum": 0.01, "maximum": 40 } ] }, { "description": "GUIDE WIRE 2.0MM SUBTALAR SYS VILEX", "code_information": [ { "code": "C1769", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 400, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 190, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 180 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 200 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 180 } ], "minimum": 0.01, "maximum": 200 } ] }, { "description": "XTRAFIX 4MM HALF PIN ZIMMER", "code_information": [ { "code": "C1769", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 549.32, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 260.93, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 247.194 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 274.66 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 247.194 } ], "minimum": 0.01, "maximum": 274.66 } ] }, { "description": "GUIDEWIRE 1.4 X 150MM SMOOTH MEDLINE", "code_information": [ { "code": "C1769", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 80, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 38, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 36 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 40 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 36 } ], "minimum": 0.01, "maximum": 40 } ] }, { "description": "XTRAFIX 5MM HALF PIN ZIMMER", "code_information": [ { "code": "C1769", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 599.28, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 284.66, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 269.676 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 299.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 269.676 } ], "minimum": 0.01, "maximum": 299.64 } ] }, { "description": "GUIDE WIRE 1.4MM 150MM L TROCAR TIP SCRE", "code_information": [ { "code": "C1769", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 840, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 399, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 378 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 420 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 378 } ], "minimum": 0.01, "maximum": 420 } ] }, { "description": "GUIDEWIRE 1.4 X 150MM SMOOTH MEDLINE", "code_information": [ { "code": "C1769", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 112, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 53.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 50.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 56 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 50.4 } ], "minimum": 0.01, "maximum": 56 } ] }, { "description": "GUIDEWIRE CURVED SENSOR .038", "code_information": [ { "code": "C1769", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 169.93, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 80.72, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 76.4685 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 84.965 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 76.4685 } ], "minimum": 0.01, "maximum": 84.965 } ] }, { "description": "WIRE WHOLEY 145CM MEDTRONIC", "code_information": [ { "code": "C1769", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 333.33, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 158.33, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 149.9985 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 166.665 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 149.9985 } ], "minimum": 0.01, "maximum": 166.665 } ] }, { "description": "XTRAFIX 6MM TRANSFIXING PIN ZIMMER", "code_information": [ { "code": "C1769", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 724.12, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 343.96, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 325.854 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 362.06 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 325.854 } ], "minimum": 0.01, "maximum": 362.06 } ] }, { "description": "XTRAFIX 4MM LARGE BLUE ZIMME", "code_information": [ { "code": "C1769", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 549.32, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 260.93, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 247.194 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 274.66 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 247.194 } ], "minimum": 0.01, "maximum": 274.66 } ] }, { "description": "GUIDEWIRE ROADRUNNER 180CM", "code_information": [ { "code": "C1769", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 128, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 60.8, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 57.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 57.6 } ], "minimum": 0.01, "maximum": 64 } ] }, { "description": "SYNCHROMED III PUMP PLUS MEDTRONIC", "code_information": [ { "code": "C1772", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 39600, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 11880, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 17820 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 19800 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 17820 } ], "minimum": 11880, "maximum": 19800 } ] }, { "description": "SYNCHROMED III PUMP PLUS MEDTRONIC", "code_information": [ { "code": "C1772", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 39600, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 11880, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 17820 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 19800 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 17820 } ], "minimum": 11880, "maximum": 19800 } ] }, { "description": "IMPLANT TOTAL KNEE SYSTEM (GENDER)2021ZI", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12036, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3610.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5416.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6018 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5416.2 } ], "minimum": 0.01, "maximum": 6018 } ] }, { "description": "IMPLANT VITAMIN E PATELLA UPCHARGE ZIMME", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 600, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 900 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 900 } ], "minimum": 0.01, "maximum": 1000 } ] }, { "description": "DOME PLUG ALLEN MEDUTLARY CEMENT PLUG", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 208.08, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 62.424, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 93.636 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 104.04 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 93.636 } ], "minimum": 0.01, "maximum": 104.04 } ] }, { "description": "IMPLANT DYNASTY PC SHELL MICROPORT ORTHO", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1200, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1800 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1800 } ], "minimum": 0.01, "maximum": 2000 } ] }, { "description": "IMPLANT DYNASTY POLY LINER MICROPORT ORT", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2580, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 774, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1161 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1290 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1161 } ], "minimum": 0.01, "maximum": 1290 } ] }, { "description": "IMPLANT PROFEMUR PLASMA SHORT NECK MI", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8400, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2520, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3780 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4200 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3780 } ], "minimum": 0.01, "maximum": 4200 } ] }, { "description": "900IMPLANT NCB LOCKING SCREW ZIMMER", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 624.24, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 187.272, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 280.908 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 312.12 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 280.908 } ], "minimum": 0.01, "maximum": 312.12 } ] }, { "description": "IMPLANT SCREW 4.0 NCB SELF TAPPING ZIMME", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 474.44, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 142.332, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 213.498 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 237.22 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 213.498 } ], "minimum": 0.01, "maximum": 237.22 } ] }, { "description": "CAPITATED T.M. REVERSE SHOULDER ZIM", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 36830, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 11049, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16573.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18415 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16573.5 } ], "minimum": 0.01, "maximum": 18415 } ] }, { "description": "TOTAL HIP W/ DUAL MOBILITY THA ZIMMER", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 26010, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7803, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 11704.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 13005 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 11704.5 } ], "minimum": 0.01, "maximum": 13005 } ] }, { "description": "IMPLANT TOTAL KNEE PRESS FIT ZIMMER", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18686.4, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5605.92, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8408.88 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9343.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8408.88 } ], "minimum": 0.01, "maximum": 9343.2 } ] }, { "description": "IMPLANT STEM TOTAL JOINT 13MM ZIMMER", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6762.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2028.78, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3043.17 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3381.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3043.17 } ], "minimum": 0.01, "maximum": 3381.3 } ] }, { "description": "IMPLANT BIOLOX DELTA FEMORAL HEAD LONG", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 900, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1350 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1350 } ], "minimum": 0.01, "maximum": 1500 } ] }, { "description": "IMPLANT BIOLOX DELTA FEMORAL HEAD MEDIUM", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 900, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1350 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1350 } ], "minimum": 0.01, "maximum": 1500 } ] }, { "description": "IMPLANT SCREW FOR TOTAL JOINT ZIMMER", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 104.04, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 31.212, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 46.818 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 52.02 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 46.818 } ], "minimum": 0.01, "maximum": 52.02 } ] }, { "description": "IMPLANT CABLE BUTTON ZIMMER", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 699.16, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 209.748, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 314.622 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 349.58 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 314.622 } ], "minimum": 0.01, "maximum": 349.58 } ] }, { "description": "CAPITATED VG CEM FEM/CEM VANGUARD KNEE", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16646.4, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4993.92, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7490.88 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 8323.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7490.88 } ], "minimum": 0.01, "maximum": 8323.2 } ] }, { "description": "IMPLANT SCREW 5.0 LONG NCB SELF TAPPING", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 674.16, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 202.248, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 303.372 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 337.08 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 303.372 } ], "minimum": 0.01, "maximum": 337.08 } ] }, { "description": "CAPITATED TOTAL KNEE LCCK CHIASSON", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 42448.32, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 12734.496, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 19101.744 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 21224.16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 19101.744 } ], "minimum": 0.01, "maximum": 21224.16 } ] }, { "description": "IMPLANT BIOLOX DELTA FEMORAL HEAD SHORT", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 900, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1350 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1350 } ], "minimum": 0.01, "maximum": 1500 } ] }, { "description": "IMPLANT PROFEMUR PLASMA LONG NECK MI", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8400, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2520, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3780 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4200 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3780 } ], "minimum": 0.01, "maximum": 4200 } ] }, { "description": "CAPITATED TM LG HIP/TM CUP WITH 2021XLPE", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19380, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5814, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8721 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9690 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8721 } ], "minimum": 0.01, "maximum": 9690 } ] }, { "description": "IMPLANT STEM TOTAL JOINT 15MM ZIMMER", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6762.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2028.78, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3043.17 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3381.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3043.17 } ], "minimum": 0.01, "maximum": 3381.3 } ] }, { "description": "IMPLANT STEM TOTAL JOINT 145MM ZIMMER", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5202, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1560.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2340.9 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2601 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2340.9 } ], "minimum": 0.01, "maximum": 2601 } ] }, { "description": "CAPITATED TOTAL HINGE KNEE CHIASSON", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 55182.8, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 16554.84, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 24832.26 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 27591.4 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 24832.26 } ], "minimum": 0.01, "maximum": 27591.4 } ] }, { "description": "IMPLANT STEM TOTAL JOINT 11MM ZIMMER", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6762.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2028.78, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3043.17 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3381.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3043.17 } ], "minimum": 0.01, "maximum": 3381.3 } ] }, { "description": "IMPLANT E CLASS DUAL MOBILITY INSERT2022", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 900, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1350 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1350 } ], "minimum": 0.01, "maximum": 1500 } ] }, { "description": "IMPLANT EMPOWR TOTAL HIP W CERAMIC HEAD", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 20000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6000, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9000 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9000 } ], "minimum": 0.01, "maximum": 10000 } ] }, { "description": "CAPITATED TOTAL HIP ZIMME", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23460, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7038, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10557 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11730 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10557 } ], "minimum": 0.01, "maximum": 11730 } ] }, { "description": "IMPLANT CERAMIC FEMORAL HEAD MICROPORT O", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 900, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1350 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1350 } ], "minimum": 0.01, "maximum": 1500 } ] }, { "description": "IMPLANT MIS COMPRESSION PT SCREW MEDLINE", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3300, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 990, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1485 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1650 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1485 } ], "minimum": 0.01, "maximum": 1650 } ] }, { "description": "IMPLANT UNICONDYLAR TIBIAL BASEPLATE SZ4", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5800, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1740, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2610 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2900 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2610 } ], "minimum": 0.01, "maximum": 2900 } ] }, { "description": "IMPLANT UNICONDYLAR TIBIAL LINER SZ4", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2800, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 840, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1260 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1400 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1260 } ], "minimum": 0.01, "maximum": 1400 } ] }, { "description": "IMPLANT UNICONDYLAR FEMORAL SZ 4", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7400, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2220, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3330 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3700 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3330 } ], "minimum": 0.01, "maximum": 3700 } ] }, { "description": "NEXGEN RH KNEE AC ART SURF", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1836, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 550.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 826.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 918 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 826.2 } ], "minimum": 0.01, "maximum": 918 } ] }, { "description": "SURFACE FOR TOTAL KNEE ZIMMER", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1872.72, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 561.816, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 842.724 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 936.36 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 842.724 } ], "minimum": 0.01, "maximum": 936.36 } ] }, { "description": "CAPITATED TOTAL KNEE LCCK CHIASSON", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 41616, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 12484.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 18727.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 20808 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 18727.2 } ], "minimum": 0.01, "maximum": 20808 } ] }, { "description": "IMPLANT PERSONA PARTIAL KNEE SYS", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 26000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7800, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 11700 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 13000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 11700 } ], "minimum": 0.01, "maximum": 13000 } ] }, { "description": "TOTAL HIP DUAL LINER MOBILITY ZIMMER", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4161.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1248.48, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1872.72 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2080.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1872.72 } ], "minimum": 0.01, "maximum": 2080.8 } ] }, { "description": "VITAMIN E INSERT DJO SURGICAL", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 600, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 900 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 900 } ], "minimum": 0.01, "maximum": 1000 } ] }, { "description": "IMPLANT DYNASTY DUAL MOBILITY LINER MICR", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 900, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1350 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1350 } ], "minimum": 0.01, "maximum": 1500 } ] }, { "description": "IMPLANT STEM TOTAL JOINT 12MM ZIMMER", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6630, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1989, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2983.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3315 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2983.5 } ], "minimum": 0.01, "maximum": 3315 } ] }, { "description": "IMPLANT DUAL MOBILITY VIVACIT VIT E 28MM", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6732, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2019.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3029.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3366 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3029.4 } ], "minimum": 0.01, "maximum": 3366 } ] }, { "description": "IMPLANT COCR FEMORAL HEAD 28MM ZIMMER", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1836, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 550.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 826.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 918 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 826.2 } ], "minimum": 0.01, "maximum": 918 } ] }, { "description": "IMPLANT OSSEOTI SHELL MULTIHOLE 54MM", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15805.76, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4741.728, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7112.592 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7902.88 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7112.592 } ], "minimum": 0.01, "maximum": 7902.88 } ] }, { "description": "IMPLANT STEM TOTAL JOINT 14MM ZIMMER", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6630, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1989, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2983.5 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3315 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2983.5 } ], "minimum": 0.01, "maximum": 3315 } ] }, { "description": "IMPLANT NEXGEN METAL AUG BLOCK SZ D 5MM", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9669.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2900.88, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4351.32 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4834.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4351.32 } ], "minimum": 0.01, "maximum": 4834.8 } ] }, { "description": "IMPLANT PORUS KNEE DR GREENE DJO SURGICA", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5700, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8550 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8550 } ], "minimum": 0.01, "maximum": 9500 } ] }, { "description": "IMPLANT CAPITATED THA DUAL MOBILITY", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21318, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6395.4, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9593.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10659 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9593.1 } ], "minimum": 0.01, "maximum": 10659 } ] }, { "description": "IMPLANT CERAMIC LONG FEMORAL HEAD MICR", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 900, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1350 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1350 } ], "minimum": 0.01, "maximum": 1500 } ] }, { "description": "IMPLANT DYNASTY DUAL MOBILITY LINER D", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 900, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1350 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1350 } ], "minimum": 0.01, "maximum": 1500 } ] }, { "description": "IMPLANT TOTAL ANKLE REPLACEMENT WRIGHT M", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 60963.8, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 18289.14, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 27433.71 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 30481.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 27433.71 } ], "minimum": 0.01, "maximum": 30481.9 } ] }, { "description": "IMPLANT CAPITATED LEFT TOTAL HIP ARTHRO", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23825.16, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 7147.548, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10721.322 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11912.58 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10721.322 } ], "minimum": 0.01, "maximum": 11912.58 } ] }, { "description": "PERSONA REVISION METAL CENTRAL CONE", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 28536, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 8560.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 12841.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 14268 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 12841.2 } ], "minimum": 0.01, "maximum": 14268 } ] }, { "description": "IMPLANT THA ACETABULAR SHELL G7 TM ZIMM", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 21848.4, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6554.52, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 9831.78 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 10924.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 9831.78 } ], "minimum": 0.01, "maximum": 10924.2 } ] }, { "description": "TRABECULAR METAL STEM 14MM ZIMMER", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9987.84, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2996.352, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4494.528 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4993.92 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4494.528 } ], "minimum": 0.01, "maximum": 4993.92 } ] }, { "description": "Joint device (implantable)", "code_information": [ { "code": "C1776", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5800, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1740, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2610 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2900 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2610 } ], "minimum": 0.01, "maximum": 2900 } ] }, { "description": "IMPLANT LEAD SURESCAN MRI 28CM MEDTRONIC", "code_information": [ { "code": "C1778", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12764, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3829.2, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5743.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6382 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5743.8 } ], "minimum": 0.01, "maximum": 6382 } ] }, { "description": "INFINION 16 CONTACT LEAD TRIAL BOSTON", "code_information": [ { "code": "C1778", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 600, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 900 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 900 } ], "minimum": 0.01, "maximum": 1000 } ] }, { "description": "OCTRODE LEAD KIT 60 CM SJM", "code_information": [ { "code": "C1778", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2400, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3600 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3600 } ], "minimum": 0.01, "maximum": 4000 } ] }, { "description": "IMPLANT PADDLE LEAD PENTA ABBOTT", "code_information": [ { "code": "C1778", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5400, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8100 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8100 } ], "minimum": 0.01, "maximum": 9000 } ] }, { "description": "IMPLANT TRIAL LEAD KIT NEVRO", "code_information": [ { "code": "C1778", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2400, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 720, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1080 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1200 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1080 } ], "minimum": 0.01, "maximum": 1200 } ] }, { "description": "OCTRODE LEAD ABBOTT", "code_information": [ { "code": "C1778", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8800, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2640, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3960 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4400 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3960 } ], "minimum": 0.01, "maximum": 4400 } ] }, { "description": "IMPLANT NEUROSTIM / LEAD KIT ROUTER", "code_information": [ { "code": "C1778", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23200, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 6960, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10440 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11600 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10440 } ], "minimum": 0.01, "maximum": 11600 } ] }, { "description": "IMPLANT MESH BARD 2 X 4 BARD DAVOL", "code_information": [ { "code": "C1781", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 160, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 48, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 72 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 80 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 72 } ], "minimum": 0.01, "maximum": 80 } ] }, { "description": "IMPLANT MESH BARD 1 X 4 BARD", "code_information": [ { "code": "C1781", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 105.2, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 31.56, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 47.34 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 52.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 47.34 } ], "minimum": 0.01, "maximum": 52.6 } ] }, { "description": "IMPLANT iSTENT GLAUKOS", "code_information": [ { "code": "C1783", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8833.2, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2649.96, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3974.94 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4416.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3974.94 } ], "minimum": 0.01, "maximum": 4416.6 } ] }, { "description": "IMPLANT COMM HANDSET KIT TH90Q01 GU US P", "code_information": [ { "code": "C1787", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5648, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1694.4, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2541.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2824 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2541.6 } ], "minimum": 0.01, "maximum": 2824 } ] }, { "description": "IMPLANT COMM HANDSET KIT TH90Q01 GU US P", "code_information": [ { "code": "C1787", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7032, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2109.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3164.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3516 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3164.4 } ], "minimum": 0.01, "maximum": 3516 } ] }, { "description": "IMPLANT COMM HANDSET KIT TH90Q01 GU US P", "code_information": [ { "code": "C1787", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6296, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1888.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2833.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3148 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2833.2 } ], "minimum": 0.01, "maximum": 3148 } ] }, { "description": "IMPLANTABLE IMPULSE GENERATOR ABBOTT", "code_information": [ { "code": "C1820", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 68000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 20400, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 30600 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 34000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 30600 } ], "minimum": 0.01, "maximum": 34000 } ] }, { "description": "IMPLANT ALPHA 3 IPG BATTERY BOSTON SCIEN", "code_information": [ { "code": "C1820", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 69200, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 20760, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 31140 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 34600 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 31140 } ], "minimum": 0.01, "maximum": 34600 } ] }, { "description": "WAVEWRITER ALPHA NEURO IPG LEAD BUNDLE B", "code_information": [ { "code": "C1820", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 78000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 23400, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 35100 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 39000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 35100 } ], "minimum": 0.01, "maximum": 39000 } ] }, { "description": "IMPLANT ALPHA NEUROSTIM SYSTEM BOSTON", "code_information": [ { "code": "C1820", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 86000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 25800, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 38700 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 43000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 38700 } ], "minimum": 0.01, "maximum": 43000 } ] }, { "description": "IMPLANTABLE IMPULSE GENERATOR ABBOTT", "code_information": [ { "code": "C1820", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 76000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 22800, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 34200 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 38000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 34200 } ], "minimum": 0.01, "maximum": 38000 } ] }, { "description": "IMPLANT IPG STIM SYS GENERATOR NEVRO", "code_information": [ { "code": "C1820", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 68000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 20400, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 30600 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 34000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 30600 } ], "minimum": 0.01, "maximum": 34000 } ] }, { "description": "IMPLANT 8MM CERVICAL PEEK VY SPINE", "code_information": [ { "code": "C1821", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT FLAREHAWK SHIM INTEGRITY IMPLANT", "code_information": [ { "code": "C1821", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2400, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3600 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3600 } ], "minimum": 0.01, "maximum": 4000 } ] }, { "description": "PIN JOINT DISTRACTOR 2.5 X 100MM MEDLINE", "code_information": [ { "code": "C1821", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 260, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 78, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 117 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 130 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 117 } ], "minimum": 0.01, "maximum": 130 } ] }, { "description": "IMPLANT 6MM CERVICAL PEEK VY SPINE", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT 6MM CERVICAL PEEK VY SPINE", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT 5MM CERVICAL PEEK VY SPINE", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT 7MM CERVICAL PEEK VY SPINE", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT LUMIVY A/T IBF 9MM TI PEEK VY SP", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT LUMIVY IBF 7MM TI PEEK VY SP", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT LUMIVY IBF 6MM TI PEEK VY SP", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT LUMIVY IBF 10MM TI PEEK VY SP", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT 12MM LUMIVy P LUMBAR IBF SYS", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT 8MM LUMIVy TLIF/LUMBAR IBF SYS", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT ACIS PROTI 7MM LORDOTIC", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT LUMIVY A/T IBF 11MM TI PEEK VY S", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT SYMPHONY SYS ROD PRE CUT", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 705.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 211.68, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 317.52 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 317.52 } ], "minimum": 0.01, "maximum": 352.8 } ] }, { "description": "IMPLANT BRICKYARD STAND ALONE 38MM PEEK", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4800, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7200 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 8000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7200 } ], "minimum": 0.01, "maximum": 8000 } ] }, { "description": "IMPLANT INSPIRE POROUS PEEK CURITEVA", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT LUMIVY A/T IBF 10MM TI PEEK VY S", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT 7MM IBF TI PEEK ZAVATION", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT ROD BONE SCREW SPINAL FIXATION S", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 705.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 211.68, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 317.52 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 317.52 } ], "minimum": 0.01, "maximum": 352.8 } ] }, { "description": "IMPLANT SILVERSTONE TITAN INTERBODY PEEK", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT INSPIRE POROUS PEEK CURITEVA", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT STANDALONE ALIF INTEBODY PISCES", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19600, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5880, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8820 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9800 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8820 } ], "minimum": 0.01, "maximum": 9800 } ] }, { "description": "IMPLANT LUMIVY A/T IBF 13MM TI PEEK VY S", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT CALIX P LUMBAR PEEK 22MM", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10192, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3057.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5096 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 } ], "minimum": 0.01, "maximum": 5096 } ] }, { "description": "IMPLANT 9MM CERVICAL PEEK", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT 7MM INSPIRE POROUS PEEK CURITEVA", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT LUMIVY A/T IBF 12MM TI PEEK VY S", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT 2 LEVEL CERVICAL FUSION PLATE AL", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 940.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT SONABLATE INSERTION HIFU PROSTAT", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3600, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5400 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5400 } ], "minimum": 0.01, "maximum": 6000 } ] }, { "description": "IMPLANT 5MM INSPIRE POROUS PEEK CURITEVA", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT STANDALONE ALIF INTEBODY PISCES", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19600, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5880, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8820 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9800 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8820 } ], "minimum": 0.01, "maximum": 9800 } ] }, { "description": "IMPLANT BRICKYARD STAND ALONE 32MM PEEK", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4800, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7200 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 8000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7200 } ], "minimum": 0.01, "maximum": 8000 } ] }, { "description": "IMPLANT IFUSE GRANITE SYSTEM 110MM SI-BO", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4200, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6300 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6300 } ], "minimum": 0.01, "maximum": 7000 } ] }, { "description": "IMPLANT CERVICAL PEEK 7MM SMS", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT LUMIVY A IBF SYS 9MM VY SPINE", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT PLIF CAGE 11MM ZAVATION", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10192, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3057.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5096 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 } ], "minimum": 0.01, "maximum": 5096 } ] }, { "description": "IMPLANT OMNI STENT SURGICAL SYSTEMS", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6936, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2080.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3121.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3468 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3121.2 } ], "minimum": 0.01, "maximum": 3468 } ] }, { "description": "IMPLANT LUMIVY A/T IBF 15MM TI PEEK VY S", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT 8MM IBF TI PEEK ZAVATION", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT 6MM CERVICAL PEEK CIF ZAVATION", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2744, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 823.2, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1234.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1372 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1234.8 } ], "minimum": 0.01, "maximum": 1372 } ] }, { "description": "IMPLANT CERVICAL SPACER", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT ACIS PROTI 8MM LORDOTIC", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT LUMIVY A IBF SYS 11MM VY SPINE", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT CALIX P LUMBAR PEEK 26 STR SMS", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT CALIX PEEK 6MM SMS", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT 4MM CERVICAL PEEK VY SPINE", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT 1 LEVEL CERVICAL FUSION PLATE AL", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 940.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT EIT LLIF 12MM CAGE DEPUY SYNTHES", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3600, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5400 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5400 } ], "minimum": 0.01, "maximum": 6000 } ] }, { "description": "IMPLANT IFUSE GRANITE SYSTEM SI-BON", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4200, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6300 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6300 } ], "minimum": 0.01, "maximum": 7000 } ] }, { "description": "IMPLANT STANDALONE ALIF PISCES-SA", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19600, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5880, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8820 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9800 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8820 } ], "minimum": 0.01, "maximum": 9800 } ] }, { "description": "IMPLANT 7MM CERVICAL PEEK INNOVASIS", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT 10MM CERVICAL PEEK 2020 GCSDM", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT 6MM INSPIRE POROUS PEEK CURITEVA", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT VIPER ROD DEPUY 40MM SYNTHES", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 704, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 211.2, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 316.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 352 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 316.8 } ], "minimum": 0.01, "maximum": 352 } ] }, { "description": "IMPLANT INSPIRE POROUS PEEK CURITEVA", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT LXHA HA PEEK 22MM INNOVASIS", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10584, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3175.2, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4762.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5292 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4762.8 } ], "minimum": 0.01, "maximum": 5292 } ] }, { "description": "IMPLANT LUMIVY A IBF SYS 14MM VY SPINE", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT LUMIVY T IBF SYS 10MM VY SPINE", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT LUMIVY T IBF SYS 12MM VY SPINE", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT PLIF CAGE 13MM ZAVATION", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10192, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3057.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5096 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 } ], "minimum": 0.01, "maximum": 5096 } ] }, { "description": "IMPLANT PLIF CAGE 9MM ZAVATION", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10192, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3057.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5096 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 } ], "minimum": 0.01, "maximum": 5096 } ] }, { "description": "IMPLANT PLIF CAGE 10MM ZAVATION", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10192, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3057.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5096 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 } ], "minimum": 0.01, "maximum": 5096 } ] }, { "description": "IMPLANT 4 LEVEL CERVICAL FUSION PLATE AL", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 940.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT SIMPLIFY DISC SZ 2 GLOBUS NUVASI", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 18816, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5644.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8467.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9408 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8467.2 } ], "minimum": 0.01, "maximum": 9408 } ] }, { "description": "IMPLANT Ti3Z PLIF 11MM ZAVATION", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT 10MM TiLATERAL INTERBODY ALTUS", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10584, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3175.2, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4762.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5292 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4762.8 } ], "minimum": 0.01, "maximum": 5292 } ] }, { "description": "IMPLANT STANDALONE ALIF INTEBODY PISCES", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19600, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5880, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8820 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9800 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8820 } ], "minimum": 0.01, "maximum": 9800 } ] }, { "description": "IMPLANT ZERO-P LORDOTIC LARGE CAGE", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7252, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2175.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3263.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3626 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3263.4 } ], "minimum": 0.01, "maximum": 3626 } ] }, { "description": "IMPLANT CALIX P LUMBAR PEEK 26X10MM SMS", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10192, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3057.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5096 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 } ], "minimum": 0.01, "maximum": 5096 } ] }, { "description": "IMPLANT AX ALIF 12 INNOVASIS", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19600, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5880, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8820 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9800 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8820 } ], "minimum": 0.01, "maximum": 9800 } ] }, { "description": "ALIF CAGE PEEK 8 X 32 2020 GCSD", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10192, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3057.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5096 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 } ], "minimum": 0.01, "maximum": 5096 } ] }, { "description": "IMPLANT CAGE SZ 14 LUMBAR GCSDM", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6860, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2058, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3087 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3430 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3087 } ], "minimum": 0.01, "maximum": 3430 } ] }, { "description": "IMPLANT 6MM CERVICAL PEEK 2021 INNOVASIS", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT 11MM CERVICAL PEEK", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT 8MM CERVICAL PEEK INNOVASIS", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT SPINE ALIF PEEK 14MM", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10192, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3057.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5096 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 } ], "minimum": 0.01, "maximum": 5096 } ] }, { "description": "IMPLANT 8MM INSPIRE POROUS PEEK CURITEVA", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT 15MM ALIF CAGE GCSDM", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10192, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3057.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5096 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 } ], "minimum": 0.01, "maximum": 5096 } ] }, { "description": "IMPLANT 16MM ALIF CAGE VY SPINE", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10192, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3057.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5096 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 } ], "minimum": 0.01, "maximum": 5096 } ] }, { "description": "IMPLANT iTIND SYSTEM OLYMPUS", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12600, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3780, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5670 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6300 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5670 } ], "minimum": 0.01, "maximum": 6300 } ] }, { "description": "IMPLANT 13MM LUMIVy P LUMBAR IBF SYS GC", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT INCORPORATE VBR CAGE SPINAL ELEM", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14248, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4274.4, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6411.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7124 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6411.6 } ], "minimum": 0.01, "maximum": 7124 } ] }, { "description": "IMPLANT ALIF CAGE 9MM GCSDM", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10192, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3057.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5096 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 } ], "minimum": 0.01, "maximum": 5096 } ] }, { "description": "IMPLANT HA PEEK 25MM INNOVASIS", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6860, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2058, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3087 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3430 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3087 } ], "minimum": 0.01, "maximum": 3430 } ] }, { "description": "IMPLANT STANDALONE ALIF INTEBODY PISCES", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19600, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 5880, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8820 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9800 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8820 } ], "minimum": 0.01, "maximum": 9800 } ] }, { "description": "IMPLANT LUMIVY A IBF SYS 10MM VY SPINE", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT POROUS PEEK TLIF SPACER 9MM CURI", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10976, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3292.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5488 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4939.2 } ], "minimum": 0.01, "maximum": 5488 } ] }, { "description": "IMPLANT PLIF CAGE 12MM ZAVATION", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10192, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3057.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5096 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4586.4 } ], "minimum": 0.01, "maximum": 5096 } ] }, { "description": "IMPLANT 9MM IBF TI PEEK ZAVATION", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1293.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT 12MM TiLATERAL INTERBODY ALTUS", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10584, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3175.2, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4762.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5292 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4762.8 } ], "minimum": 0.01, "maximum": 5292 } ] }, { "description": "IMPLANT SILVERSTONE 10MM PEEK ALTUS SPIN", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6860, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2058, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3087 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3430 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3087 } ], "minimum": 0.01, "maximum": 3430 } ] }, { "description": "IMPLANT SILVERSTONE TI LATERAL PEEK", "code_information": [ { "code": "C1889", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10584, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 3175.2, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4762.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5292 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4762.8 } ], "minimum": 0.01, "maximum": 5292 } ] }, { "description": "DILATOR SHEALTH SET 810", "code_information": [ { "code": "C1892", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 216.4, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 102.79, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 97.38 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 108.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 97.38 } ], "minimum": 0.01, "maximum": 108.2 } ] }, { "description": "URETERAL ACCESS SHEATH", "code_information": [ { "code": "C1894", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 420, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 199.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 189 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 210 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 189 } ], "minimum": 0.01, "maximum": 210 } ] }, { "description": "PINNACLE SHEALTH 8FR TERUMO", "code_information": [ { "code": "C1894", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 41.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 19.76, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 18.72 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.72 } ], "minimum": 0.01, "maximum": 20.8 } ] }, { "description": "PINNACLE SHEALTH 11FR TERUMO", "code_information": [ { "code": "C1894", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 41.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 19.76, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 18.72 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.72 } ], "minimum": 0.01, "maximum": 20.8 } ] }, { "description": "FLEXOR URETERAL SHEATH 35CM COOK", "code_information": [ { "code": "C1894", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 527.52, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 250.57, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 237.384 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 263.76 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 237.384 } ], "minimum": 0.01, "maximum": 263.76 } ] }, { "description": "OPEN END URETERAL CATHETER GLS", "code_information": [ { "code": "C1894", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 32, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 15.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 14.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.4 } ], "minimum": 0.01, "maximum": 16 } ] }, { "description": "PRELUDE SNAP INTRODUCER 6F MERIT", "code_information": [ { "code": "C1894", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 252, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 119.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 113.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 126 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 113.4 } ], "minimum": 0.01, "maximum": 126 } ] }, { "description": "FLEXOR URETERAL DILATOR 45CM", "code_information": [ { "code": "C1894", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 527.52, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 250.57, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 237.384 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 263.76 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 237.384 } ], "minimum": 0.01, "maximum": 263.76 } ] }, { "description": "IMPLANT LEAD DURATA 7122Q BIV SJM", "code_information": [ { "code": "C1895", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4400, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1320, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1980 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2200 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1980 } ], "minimum": 0.01, "maximum": 2200 } ] }, { "description": "OCTRODE LEAD KIT SJM 3086", "code_information": [ { "code": "C1897", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 600, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 900 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 900 } ], "minimum": 0.01, "maximum": 1000 } ] }, { "description": "IMPLANT PACE LEAD ST JD W/ SYSCEL PM1272", "code_information": [ { "code": "C1898", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1200, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 360, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 540 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 600 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 540 } ], "minimum": 0.01, "maximum": 600 } ] }, { "description": "IMPLANT 6FRX26 UNIVERSA SOFT URETERAL ST", "code_information": [ { "code": "C2617", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 416.4, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 124.92, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 187.38 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 208.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 187.38 } ], "minimum": 0.01, "maximum": 208.2 } ] }, { "description": "IMPLANT 6FRX24 UNIVERSA SOFT URETERAL ST", "code_information": [ { "code": "C2617", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 416.4, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 124.92, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 187.38 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 208.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 187.38 } ], "minimum": 0.01, "maximum": 208.2 } ] }, { "description": "IMPLANT 6FRX22 UNIVERSA SOFT URETERAL ST", "code_information": [ { "code": "C2617", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 416.4, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 124.92, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 187.38 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 208.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 187.38 } ], "minimum": 0.01, "maximum": 208.2 } ] }, { "description": "IMPLANT 6FRX28 UNIVERSA SOFT URETERAL ST", "code_information": [ { "code": "C2617", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 360.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 108.18, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 162.27 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 180.3 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 162.27 } ], "minimum": 0.01, "maximum": 180.3 } ] }, { "description": "IMPLANT CARDIOMEMS PA SENSOR SYSTEM", "code_information": [ { "code": "C2624", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 78000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 23400, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 35100 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 39000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 35100 } ], "minimum": 0.01, "maximum": 39000 } ] }, { "description": "IMPLANT PROPEL REG SIZE INTERSECT ENT", "code_information": [ { "code": "C2625", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4012, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1203.6, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1805.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2006 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1805.4 } ], "minimum": 0.01, "maximum": 2006 } ] }, { "description": "IMPLANT CONTOUR STENT INTERSECT ENT", "code_information": [ { "code": "C2625", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3836, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1150.8, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1726.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1918 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1726.2 } ], "minimum": 0.01, "maximum": 1918 } ] }, { "description": "PAIN PUMP ON-Q I FLOW KIMBER CLARK", "code_information": [ { "code": "C2626", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1484, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 704.9, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 667.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 742 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 667.8 } ], "minimum": 0.01, "maximum": 742 } ] }, { "description": "CATHETER 16 FR 2 WAY FOLEY LATEX MEDLINE", "code_information": [ { "code": "C2627", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3.68, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1.75, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1.656 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.84 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1.656 } ], "minimum": 0.01, "maximum": 1.84 } ] }, { "description": "SURGIFLO HEMO MATRIX W/THROMBIN J&J", "code_information": [ { "code": "C9250", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 699.67, "discounted_cash": 253.08, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 149.33, "additional_payer_notes": "125% of the Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 119.46, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 245.56 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 245.56 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 126.54, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 170.829, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 126.54, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 153.1134, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 117.07, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 332.34, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 328.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 126.54, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 202.464, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 147.82, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 126.54, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 131.6 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 314.8515 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 349.835 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 314.8515 } ], "minimum": 117.07, "maximum": 349.835 } ] }, { "description": "TISSEEL 4ML FROZEN FIBRIN SEALANT BAXTE", "code_information": [ { "code": "C9250", "type": "HCPCS" }, { "code": "272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1021.16, "discounted_cash": 253.08, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 149.33, "additional_payer_notes": "125% of the Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 119.46, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 245.56 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 245.56 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 126.54, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 170.829, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 126.54, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 153.1134, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 117.07, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 485.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 328.52, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 126.54, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 202.464, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 147.82, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 126.54, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 131.6 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 459.522 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 510.58 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 459.522 } ], "minimum": 117.07, "maximum": 510.58 } ] }, { "description": "URETEROSCOPE HOOVER STEERABLE ACCESS", "code_information": [ { "code": "C9761", "type": "HCPCS" }, { "code": "278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2780, "discounted_cash": 17180, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8212.95, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 4108.06 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 4335.717852 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8589.84, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 11596.5, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8590, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 10393.9, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8048.69, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 834, "additional_payer_notes": "cost plus 20%" }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 22585.61, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8590, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 13744, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 10368.17, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 8590, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 9247.15 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1251 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1390 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1251 } ], "minimum": 834, "maximum": 22585.61 } ] }, { "description": "CRUTCH MEDIUM ADULT MEDLINE", "code_information": [ { "code": "E0114", "type": "HCPCS" }, { "code": "270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 46.28, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.98, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 20.826 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.14 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.826 } ], "minimum": 0.01, "maximum": 23.14 } ] }, { "description": "Inj for sacroiliac jt anesth", "code_information": [ { "code": "G0260", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2311.88, "discounted_cash": 1281.02, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 768.84, "additional_payer_notes": "125% of the Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 615.07, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 606.8 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 640.42623 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.51, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 864.6885, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.51, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 775.0171, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 602.77, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 359.35, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1098.14, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1691.44, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.51, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1024.816, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 773.12, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 640.51, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 692.52 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1040.346 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1155.94 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1040.346 } ], "minimum": 359.35, "maximum": 1691.44 } ] }, { "description": "OBSERVATION PER HOUR", "code_information": [ { "code": "G0378", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 93.6, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.96512, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 20.41 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 21.537092 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.96512, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.96512, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.96512, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 44.46, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 42.12 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 46.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 42.12 } ], "minimum": 13.96512, "maximum": 46.8 } ] }, { "description": "PATH - SURG GROSS & MICRO PROSTATE 1-20", "code_information": [ { "code": "G0416", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 962, "discounted_cash": 650.5, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 399.36, "additional_payer_notes": "125% of the Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 319.49, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 275.13 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 290.381886 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.25, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 439.09, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.25, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 393.5525, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 313.1, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 456.95, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 878.6, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.25, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 520.4, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 392.59, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 325.25, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 359.72 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 432.9 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 481 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 432.9 } ], "minimum": 275.13, "maximum": 878.6 } ] }, { "description": "NICOTINE METABOLITES, SERUM", "code_information": [ { "code": "G0480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 182, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 88.57, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 111.09 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 117.244978 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 88.57, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 114.43, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 88.57, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 88.57, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 86.45, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 314.68, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 81.9 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 91 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 81.9 } ], "minimum": 81.9, "maximum": 314.68 } ] }, { "description": "SUCCINYLCHOLINE 200 MG/10 ML VIAL", "code_information": [ { "code": "J0330", "type": "HCPCS" }, { "code": "51079-0753-01", "type": "NDC" } ], "drug_information": { "unit": 200, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 45, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.38, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 20.25 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.25 } ], "minimum": 1.01, "maximum": 22.5 } ] }, { "description": "SUCCINYLCHOLINE 200 MG/10 ML SYRINGE", "code_information": [ { "code": "J0330", "type": "HCPCS" }, { "code": "76329-3013-05", "type": "NDC" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 77.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 36.81, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 34.875 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 38.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 34.875 } ], "minimum": 1.01, "maximum": 38.75 } ] }, { "description": "HYDRALAZINE (APRESOLINE) INJ 20 MG/ML", "code_information": [ { "code": "J0360", "type": "HCPCS" } ], "drug_information": { "unit": 20, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 117, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.34 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.34 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 55.575, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 52.65 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 58.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 52.65 } ], "minimum": 6.34, "maximum": 58.5 } ] }, { "description": "ATROPINE INJ 0.1 MG/ML 10 ML SYRINGE", "code_information": [ { "code": "J0461", "type": "HCPCS" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 72.15, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.29725, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.1 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.1 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.29725, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.29725, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 8.29725, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 34.27125, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 32.4675 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 36.075 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 32.4675 } ], "minimum": 0.1, "maximum": 36.075 } ] }, { "description": "BOTOX THERAPEUTIC INJ : 100 U", "code_information": [ { "code": "J0585", "type": "HCPCS" }, { "code": "25021-0673-77", "type": "NDC" } ], "drug_information": { "unit": 100, "type": "UN" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 5039, "discounted_cash": 11.56, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.23, "additional_payer_notes": "125% of the Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.75, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.39 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.39 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.75, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.8, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.9938, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.64, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2393.525, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 15.81, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.248, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7.11, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6.01 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2267.55 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2519.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2267.55 } ], "minimum": 5.64, "maximum": 2519.5 } ] }, { "description": "Injection,onabotulinumtoxina", "code_information": [ { "code": "J0585", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 5077.8, "discounted_cash": 11.56, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.23, "additional_payer_notes": "125% of the Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.75, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.39 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.39 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.7463952, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 7.8, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 6.9938, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.63, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2411.955, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 15.8, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 9.248, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 7.11, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 5.78, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 6.01 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2285.01 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2538.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2285.01 } ], "minimum": 5.63, "maximum": 2538.9 } ] }, { "description": "CALCIUM GLUCONATE INJ : 10% 10 ML VIAL", "code_information": [ { "code": "J0610", "type": "HCPCS" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 78, "payers_information": [ { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 37.05, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 35.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 39 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 35.1 } ], "minimum": 35.1, "maximum": 39 } ] }, { "description": "METOPROLOL TART INJ 5 MG/5 ML", "code_information": [ { "code": "J0616", "type": "HCPCS" } ], "drug_information": { "unit": 5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.13 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.2625, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 0.13, "maximum": 9.75 } ] }, { "description": "BUPIVACAINE MPF INJ : 0.5% 10 ML", "code_information": [ { "code": "J0665", "type": "HCPCS" } ], "drug_information": { "unit": 0.5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.02 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.02 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.1625, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.575 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.575 } ], "minimum": 0.02, "maximum": 11.75 } ] }, { "description": "Bupivacaine Liposome 1.3% 266mg/20ml", "code_information": [ { "code": "J0666", "type": "HCPCS" } ], "drug_information": { "unit": 20, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 2933.75, "discounted_cash": 2.56, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 0.92, "additional_payer_notes": "125% of the Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1.28, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 337.38125, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1.59 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1.28, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 337.38125, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1.73, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1.28, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 1.5488, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1.2544, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 337.38125, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 337.38125, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1393.53125, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1.28, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 2.048, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1.59, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 1.28 }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 1.33 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1320.1875 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1466.875 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1320.1875 } ], "minimum": 0.92, "maximum": 1466.875 } ] }, { "description": "CEFAZOLIN INJ 1GM", "code_information": [ { "code": "J0687", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1.06 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.2625, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 1.06, "maximum": 9.75 } ] }, { "description": "CEFAZOLIN INJ 3GM", "code_information": [ { "code": "J0688", "type": "HCPCS" }, { "code": "44567-0840-25", "type": "NDC" } ], "drug_information": { "unit": 3, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 46.02, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.2923, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1.03 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.2923, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 0.87, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.2923, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.2923, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.8595, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 2.45, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1.1, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 20.709 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.01 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 20.709 } ], "minimum": 0.87, "maximum": 23.01 } ] }, { "description": "CEFAZOLIN INJ 2GM", "code_information": [ { "code": "J0690", "type": "HCPCS" } ], "drug_information": { "unit": 2, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 47.5, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.4625, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.8 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.8 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.4625, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.4625, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 5.4625, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 22.5625, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 21.375 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 23.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 21.375 } ], "minimum": 0.8, "maximum": 23.75 } ] }, { "description": "CEFTRIAXONE (ROCEPHIN) INJ 1 GM VIAL", "code_information": [ { "code": "J0696", "type": "HCPCS" } ], "drug_information": { "unit": 1, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 113.75, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.08125, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.52 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.52 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.08125, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.08125, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 13.08125, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 54.03125, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 51.1875 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 56.875 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 51.1875 } ], "minimum": 0.52, "maximum": 56.875 } ] }, { "description": "BETAMETHASONE ACET/NA PHOS INJ : 5 ML", "code_information": [ { "code": "J0702", "type": "HCPCS" } ], "drug_information": { "unit": 5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 291.85, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 7.05 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 7.05 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 138.62875, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 131.3325 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 145.925 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 131.3325 } ], "minimum": 7.05, "maximum": 145.925 } ] }, { "description": "CIPROFLOXACIN (CIPRO) IVPB 400 MG", "code_information": [ { "code": "J0744", "type": "HCPCS" } ], "drug_information": { "unit": 400, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 58.5, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7275, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2.01 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7275, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7275, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7275, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 27.7875, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 26.325 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.325 } ], "minimum": 2.01, "maximum": 29.25 } ] }, { "description": "PROCHLORPERAZINE 10 MG/2 ML IV", "code_information": [ { "code": "J0780", "type": "HCPCS" }, { "code": "00904-6461-61", "type": "NDC" } ], "drug_information": { "unit": 10, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 35.8, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.117, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3.14 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.117, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.117, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 4.117, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.005, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.11 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 17.9 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.11 } ], "minimum": 3.14, "maximum": 17.9 } ] }, { "description": "DAPTOMYCIN (CUBICIN) INJ : 500 MG", "code_information": [ { "code": "J0878", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 154, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.04 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.04 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 73.15, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 69.3 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 77 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 69.3 } ], "minimum": 0.04, "maximum": 77 } ] }, { "description": "METHYLPRED ACETATE INJ 40 MG/ML", "code_information": [ { "code": "J1010", "type": "HCPCS" }, { "code": "00009-3073-01", "type": "NDC" } ], "drug_information": { "unit": 40, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 75.16, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.12 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 35.701, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 0.3, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 0.13, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 33.822 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 37.58 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 33.822 } ], "minimum": 0.12, "maximum": 37.58 } ] }, { "description": "METHYLPRED ACETATE INJ 80 MG/ML VIAL", "code_information": [ { "code": "J1010", "type": "HCPCS" }, { "code": "78112-0694-80", "type": "NDC" } ], "drug_information": { "unit": 80, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 153.85, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.12 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 73.07875, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 0.3, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 0.13, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 69.2325 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 76.925 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 69.2325 } ], "minimum": 0.12, "maximum": 76.925 } ] }, { "description": "DEXTENZA OPHTH INSERT ER 0.4MG", "code_information": [ { "code": "J1096", "type": "HCPCS" }, { "code": "70382-0204-01", "type": "NDC" } ], "drug_information": { "unit": 0.4, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 4992, "discounted_cash": 175.24, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 109.53, "additional_payer_notes": "125% of the Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 87.62, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 149.85 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 149.85 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 87.62, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 118.29, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 87.62, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 106.0202, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 85.8676, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2371.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 275.88, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 87.62, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 140.192, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 124.13, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 87.62, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 91.12 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2246.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2496 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2246.4 } ], "minimum": 85.8676, "maximum": 2496 } ] }, { "description": "DEXAMETHASONE (DECADRON) INJ 4 MG/ML 1ML", "code_information": [ { "code": "J1100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.14 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.2625, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 0.14, "maximum": 9.75 } ] }, { "description": "HYDROmorphone 10mg/50ml (0.2mg/ml)PCA", "code_information": [ { "code": "J1171", "type": "HCPCS" }, { "code": "42023-0187-10", "type": "NDC" } ], "drug_information": { "unit": 50, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 355.25, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.15 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 168.74375, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 0.22, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 0.1, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 159.8625 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 177.625 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 159.8625 } ], "minimum": 0.1, "maximum": 177.625 } ] }, { "description": "DIPHENHYDRAMINE (BENADRYL) INJ 50MG/ML", "code_information": [ { "code": "J1200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.48, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.7002, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.94 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.94 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.7002, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.7002, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.7002, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.153, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.566 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.74 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.566 } ], "minimum": 0.94, "maximum": 11.74 } ] }, { "description": "GENTAMICIN INJ 80 MG/2 ML VIAL", "code_information": [ { "code": "J1580", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 31.75, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.65125, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 3.21 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 3.21 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.65125, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.65125, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.65125, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 15.08125, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 14.2875 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.875 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 14.2875 } ], "minimum": 3.21, "maximum": 15.875 } ] }, { "description": "HEPARIN LOCK 100 UNITS/ML 5 ML PFS", "code_information": [ { "code": "J1642", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.02 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.02 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.2625, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 0.02, "maximum": 9.75 } ] }, { "description": "HEPARIN INF : 2,000 UNITS/NS 1000 ML", "code_information": [ { "code": "J1644", "type": "HCPCS" }, { "code": "00338-0433-04", "type": "NDC" } ], "drug_information": { "unit": 1000, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 58.5, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7275, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.31 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.31 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7275, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7275, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.7275, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 27.7875, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 26.325 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.325 } ], "minimum": 0.31, "maximum": 29.25 } ] }, { "description": "ENOXAPARIN (LOVENOX) INJ 40 MG", "code_information": [ { "code": "J1650", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 60.13, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.91495, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.73 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.73 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.91495, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.91495, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.91495, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 28.56175, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 27.0585 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 30.065 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 27.0585 } ], "minimum": 0.73, "maximum": 30.065 } ] }, { "description": "HYDROCORTISONE SOD SUCC INJ 100 MG", "code_information": [ { "code": "J1720", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 142.29, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.36335, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 19.44 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 19.44 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.36335, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.36335, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 16.36335, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 67.58775, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 64.0305 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 71.145 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 64.0305 } ], "minimum": 16.36335, "maximum": 71.145 } ] }, { "description": "INSULIN REGULAR (HUMULIN-R) 10ml", "code_information": [ { "code": "J1815", "type": "HCPCS" }, { "code": "00002-8215-01", "type": "NDC" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 347.95, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 40.01425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.56 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.56 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 40.01425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 40.01425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 40.01425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 165.27625, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 156.5775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 173.975 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 156.5775 } ], "minimum": 0.56, "maximum": 173.975 } ] }, { "description": "KETOROLAC (TORODOL) INJ 30 MG/1 ML", "code_information": [ { "code": "J1885", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.93, "discounted_cash": 0.6, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 0.37, "additional_payer_notes": "125% of the Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 0.3, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.67 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.67 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 0.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 0.41, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 0.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 0.363, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 0.294, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.19175, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 0.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 0.48, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 0.82, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 0.3, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 0.31 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 22.9185 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 25.465 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 22.9185 } ], "minimum": 0.294, "maximum": 25.465 } ] }, { "description": "FUROSEMIDE (LASIX) INJ 20 MG/2 ML", "code_information": [ { "code": "J1941", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 221.94 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 221.94 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.2625, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 8.775, "maximum": 221.94 } ] }, { "description": "LORAZEPAM (ATIVAN) INJ 2 MG/ML", "code_information": [ { "code": "J2060", "type": "HCPCS" }, { "code": "00641-6044-01", "type": "NDC" } ], "drug_information": { "unit": 1, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1.11 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1.11 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.2625, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 1.11, "maximum": 9.75 } ] }, { "description": "MEROPENEM (MERREM) INJ 1 GM", "code_information": [ { "code": "J2183", "type": "HCPCS" }, { "code": "00310-0321-30", "type": "NDC" } ], "drug_information": { "unit": 1, "type": "GM" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 338, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1.76 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1.82 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.55, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4.04, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1.81, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 152.1 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 169 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 152.1 } ], "minimum": 1.76, "maximum": 169 } ] }, { "description": "MEROPENEM (MERREM) INJ 500 MG", "code_information": [ { "code": "J2183", "type": "HCPCS" }, { "code": "55150-0207-20", "type": "NDC" } ], "drug_information": { "unit": 500, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 169, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1.76 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1.82 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 80.275, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 4.04, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 1.81, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 76.05 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 84.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 76.05 } ], "minimum": 1.76, "maximum": 84.5 } ] }, { "description": "PANTOPRAZOLE-(PROTONIX)-INJ 40 MG", "code_information": [ { "code": "J2471", "type": "HCPCS" }, { "code": "55150-0202-00", "type": "NDC" } ], "drug_information": { "unit": 40, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 55.25, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.35375, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 7.02 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.35375, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.35375, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 6.35375, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.24375, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 24.8625 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 27.625 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 24.8625 } ], "minimum": 6.35375, "maximum": 27.625 } ] }, { "description": "DESMOPRESSIN (DDAVP) INJ : 4MCG/ML 10 ML", "code_information": [ { "code": "J2597", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1300, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 6.77 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 6.77 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 617.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 585 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 650 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 585 } ], "minimum": 6.77, "maximum": 650 } ] }, { "description": "METOCLOPRAMIDE (REGLAN) INJ 10 MG/2 ML", "code_information": [ { "code": "J2765", "type": "HCPCS" }, { "code": "00703-4502-04", "type": "NDC" } ], "drug_information": { "unit": 10, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1.22 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1.22 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.2625, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 1.22, "maximum": 9.75 } ] }, { "description": "MORPHINE SO4 INJ 10 MG/ML", "code_information": [ { "code": "J2770", "type": "HCPCS" }, { "code": "63323-0451-00", "type": "NDC" } ], "drug_information": { "unit": 10, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 19.5, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 503.29 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 503.29 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 2.2425, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 9.2625, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 10.4, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 4.68, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 8.775 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 9.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.775 } ], "minimum": 2.2425, "maximum": 503.29 } ] }, { "description": "METHYLPRED SOD SUCC INJ 40 MG VIAL", "code_information": [ { "code": "J2919", "type": "HCPCS" }, { "code": "00409-5684-23", "type": "NDC" } ], "drug_information": { "unit": 40, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 37.44, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.28 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 17.784, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 0.66, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 0.3, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 16.848 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 18.72 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.848 } ], "minimum": 0.28, "maximum": 18.72 } ] }, { "description": "METHYLPRED SOD SUCC INJ 125 MG VIAL", "code_information": [ { "code": "J2919", "type": "HCPCS" }, { "code": "63323-0258-03", "type": "NDC" } ], "drug_information": { "unit": 125, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 59.28, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.28 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 28.158, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 0.66, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 0.3, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 26.676 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 29.64 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 26.676 } ], "minimum": 0.28, "maximum": 29.64 } ] }, { "description": "FENTANYL INJ 250 MCG/5ML", "code_information": [ { "code": "J3010", "type": "HCPCS" }, { "code": "00409-9094-25", "type": "NDC" } ], "drug_information": { "unit": 250, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 25.66, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.94 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.94 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 12.1885, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 11.547 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 12.83 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.547 } ], "minimum": 0.94, "maximum": 12.83 } ] }, { "description": "DIAZEPAM (VALIUM) SYRINGE 10 MG/2 ML", "code_information": [ { "code": "J3360", "type": "HCPCS" }, { "code": "43598-0106-11", "type": "NDC" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 192, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 22.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 8.23 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 8.23 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 22.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 22.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 22.08, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 91.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 86.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 96 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 86.4 } ], "minimum": 8.23, "maximum": 96 } ] }, { "description": "VANCOMYCIN INJ 750 MG", "code_information": [ { "code": "J3373", "type": "HCPCS" }, { "code": "67457-0705-75", "type": "NDC" } ], "drug_information": { "unit": 750, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 76.7, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.03 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.03 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 36.4325, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 34.515 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 38.35 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 34.515 } ], "minimum": 0.03, "maximum": 38.35 } ] }, { "description": "15ml (Guillot)NASAL SPRAY(Afrin) 0.05%", "code_information": [ { "code": "J3490", "type": "HCPCS" }, { "code": "00904-7435-35", "type": "NDC" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 15.5, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.7825, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.7825, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.7825, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.7825, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 7.3625, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.975 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.975 } ], "minimum": 1.7825, "maximum": 7.75 } ] }, { "description": "SOD CHLORIDE IVSOL .9% 1000ML MEDLINE", "code_information": [ { "code": "J7030", "type": "HCPCS" }, { "code": "00264-7800-00", "type": "NDC" } ], "drug_information": { "unit": 100, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 7.21, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 0.82915, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2.84 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2.84 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 0.82915, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 0.82915, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 0.82915, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.42475, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.2445 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.605 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.2445 } ], "minimum": 0.82915, "maximum": 3.605 } ] }, { "description": "D5 .45% 1000ML IVSOL HALF NORMAL", "code_information": [ { "code": "J7030", "type": "HCPCS" }, { "code": "00338-0085-04", "type": "NDC" } ], "drug_information": { "unit": 1000, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.67, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.34205, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2.84 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2.84 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.34205, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.34205, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.34205, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.54325, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.2515 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.835 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.2515 } ], "minimum": 1.34205, "maximum": 5.835 } ] }, { "description": "SOD CHLORIDE INJ 0.9% : 250 ML", "code_information": [ { "code": "J7030", "type": "HCPCS" }, { "code": "00409-7984-06", "type": "NDC" } ], "drug_information": { "unit": 250, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 33.43, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.84445, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2.84 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2.84 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.84445, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.84445, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 3.84445, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 15.87925, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 15.0435 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 16.715 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 15.0435 } ], "minimum": 2.84, "maximum": 16.715 } ] }, { "description": "SOL 0.9% SOL CHL 500ML IV SOL", "code_information": [ { "code": "J7040", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9.2, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.058, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1.42 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1.42 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.058, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.058, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.058, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4.37, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.14 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.14 } ], "minimum": 1.058, "maximum": 4.6 } ] }, { "description": "DEX+SOD CHL IVSOL 5-0.9% 1000ML", "code_information": [ { "code": "J7042", "type": "HCPCS" }, { "code": "00338-0089-04", "type": "NDC" } ], "drug_information": { "unit": 1000, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 17.04, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1.29 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1.29 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 8.094, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 7.668 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 8.52 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.668 } ], "minimum": 1.29, "maximum": 8.52 } ] }, { "description": "LAC RING IVSOL 1000ML MEDLINE", "code_information": [ { "code": "J7120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8.28, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 0.9522, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2.7 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 0.9522, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 0.9522, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 0.9522, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 3.933, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3.726 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.14 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.726 } ], "minimum": 0.9522, "maximum": 4.14 } ] }, { "description": "LAC RING IVSOL 500ML MEDLINE", "code_information": [ { "code": "J7120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10.84, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.2466, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2.7 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.2466, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.2466, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.2466, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.149, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4.878 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.42 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4.878 } ], "minimum": 1.2466, "maximum": 5.42 } ] }, { "description": "LAC RING D5 DEXT IVSOL 500ML MEDLINE", "code_information": [ { "code": "J7120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14.63, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.68245, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 2.7 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 2.7 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.68245, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.68245, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.68245, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.94925, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 6.5835 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 7.315 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.5835 } ], "minimum": 1.68245, "maximum": 7.315 } ] }, { "description": "D5 LAC RING+DEX IVSOL 5% 1000ML", "code_information": [ { "code": "J7121", "type": "HCPCS" }, { "code": "00264-7751-00", "type": "NDC" } ], "drug_information": { "unit": 1, "type": "EA" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.29, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.29835, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 8.82 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 8.82 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.29835, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.29835, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 1.29835, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.36275, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.0805 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.645 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.0805 } ], "minimum": 1.29835, "maximum": 8.82 } ] }, { "description": "ALBUTEROL INH SOLN 0.042% 1.25 MG/3 ML", "code_information": [ { "code": "J7613", "type": "HCPCS" }, { "code": "00487-9904-25", "type": "NDC" } ], "drug_information": { "unit": 1.25, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 11.38, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.04 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.04 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5.4055, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.121 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.69 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.121 } ], "minimum": 0.04, "maximum": 5.69 } ] }, { "description": "IPRATROPIUM BR INH SOLN 0.5 MG/2.5ML", "code_information": [ { "code": "J7644", "type": "HCPCS" }, { "code": "00487-9801-01", "type": "NDC" } ], "drug_information": { "unit": 0.5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 13, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.35 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.35 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 6.175, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5.85 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 6.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5.85 } ], "minimum": 0.35, "maximum": 6.5 } ] }, { "description": "IMPLANT BULKAMID URETHRAL BULKING", "code_information": [ { "code": "L8606", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4600, "payers_information": [ { "payer_name": "Aetna Better Health", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 686.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 213.19 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 225.00216 }, { "payer_name": "Healthy Blue", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 686.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "Humana Healthy Horizons", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 686.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LA Healthcare Connections", "plan_name": "Medicaid", "methodology": "fee schedule", "standard_charge_dollar": 686.32, "additional_payer_notes": "100% of medicaid fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2185, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2070 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2300 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2070 } ], "minimum": 213.19, "maximum": 2300 } ] }, { "description": "IMPLANT iSTENT INJECT STENT", "code_information": [ { "code": "L8612", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8425.2, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 621.03 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 655.446866 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4001.97, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3791.34 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4212.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3791.34 } ], "minimum": 621.03, "maximum": 4212.6 } ] }, { "description": "IMPLANT CURVED ROD", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 784, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 372.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 352.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 392 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.8 } ], "minimum": 0.01, "maximum": 392 } ] }, { "description": "UROLIFT RELOAD CARTRIDGE IMPLANT", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1900, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1800 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1800 } ], "minimum": 0.01, "maximum": 2000 } ] }, { "description": "IMPLANT ROD LUMBAR VY SPINE", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 705.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 335.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 317.52 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 317.52 } ], "minimum": 0.01, "maximum": 352.8 } ] }, { "description": "IMPLANT PCT CURVED ROD VY SPINE", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 705.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 335.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 317.52 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 317.52 } ], "minimum": 0.01, "maximum": 352.8 } ] }, { "description": "UROLIFT GUN + CARTRIDGE KIT IMPLANT", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1900, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1800 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1800 } ], "minimum": 0.01, "maximum": 2000 } ] }, { "description": "IMPLANT 6.5MM REDUCTION SCREW SPINAL ELE", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3234, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1536.15, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1455.3 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1617 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1455.3 } ], "minimum": 0.01, "maximum": 1617 } ] }, { "description": "IMPLANT STRAIGHT ROD", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 784, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 372.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 352.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 392 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.8 } ], "minimum": 0.01, "maximum": 392 } ] }, { "description": "IMPLANT YUKON PCF SET SCREW 2020STRYKER", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 196, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 93.1, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 88.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 98 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 88.2 } ], "minimum": 0.01, "maximum": 98 } ] }, { "description": "IMPLANT EVEREST ROD 5.5 STRYKER SPINE", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 600, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 285, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 270 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 300 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 270 } ], "minimum": 0.01, "maximum": 300 } ] }, { "description": "IMPLANT CURVED ROD FOR PCT VY SPINE", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 705.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 335.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 317.52 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 317.52 } ], "minimum": 0.01, "maximum": 352.8 } ] }, { "description": "IMPLANT ROD 400MM LUMBAR GCSDM", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 784, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 372.4, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 352.8 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 392 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.8 } ], "minimum": 0.01, "maximum": 392 } ] }, { "description": "IMPLANT YUKON PCF SCREW 3.5 STRYKER SPIN", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT DUAL TULIP OPEN ROD CONNECTOR", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3332, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1582.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1499.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1666 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1499.4 } ], "minimum": 0.01, "maximum": 1666 } ] }, { "description": "IMPLANT 8.5MM SCREW LUMBAR VY SPINE", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT CERVICAL SPACER 6MM NANOHIVE MED", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4312, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2048.2, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2156 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1940.4 } ], "minimum": 0.01, "maximum": 2156 } ] }, { "description": "IMPLANT 2 LEVEL PLATE ZAVATION", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3136, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1489.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1568 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1411.2 } ], "minimum": 0.01, "maximum": 1568 } ] }, { "description": "IMPLANT X-LINK 50MM LUMBAR VY SPINE", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3332, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1582.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1499.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1666 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1499.4 } ], "minimum": 0.01, "maximum": 1666 } ] }, { "description": "IMPLANT HOOKED OPEN ROD CONNECTOR 11.5MM", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3332, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1582.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1499.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1666 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1499.4 } ], "minimum": 0.01, "maximum": 1666 } ] }, { "description": "IMPLANT NEUROLAC 4.0MM BIOPRO", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4275, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4050 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4050 } ], "minimum": 0.01, "maximum": 4500 } ] }, { "description": "IMPLANT 7.5MM REDUCTION SCREW SPINAL ELE", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3234, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1536.15, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1455.3 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1617 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1455.3 } ], "minimum": 0.01, "maximum": 1617 } ] }, { "description": "IMPLANT ROD 400MM LUMBAR GCSDM", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 705.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 335.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 317.52 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 317.52 } ], "minimum": 0.01, "maximum": 352.8 } ] }, { "description": "IMPLANT STRAIGHT ROD ALTUS SPINE", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 705.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 335.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 317.52 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 317.52 } ], "minimum": 0.01, "maximum": 352.8 } ] }, { "description": "IMPLANT YUKON PCF SCREW 4.0 STRYKER SPIN", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2548, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1210.3, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1274 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1146.6 } ], "minimum": 0.01, "maximum": 1274 } ] }, { "description": "IMPLANT YUKON PCF ROD STRYKER SPINE", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 600, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 285, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 270 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 300 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 270 } ], "minimum": 0.01, "maximum": 300 } ] }, { "description": "IMPLANT 5.5 ROD LUMBAR 2020 GCSDM", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 705.6, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 335.16, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 317.52 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 352.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 317.52 } ], "minimum": 0.01, "maximum": 352.8 } ] }, { "description": "IMPLANT ROD STRYKER SPINE", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 600, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 285, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 270 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 300 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 270 } ], "minimum": 0.01, "maximum": 300 } ] }, { "description": "IMPLANT AXOGUARD NERVE CONNECTOR 3X15", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8776, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4168.6, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3949.2 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4388 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3949.2 } ], "minimum": 0.01, "maximum": 4388 } ] }, { "description": "IMPLANT AXOGUARD NERVE CONNECTOR 4X15", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8560, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4066, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3852 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4280 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3852 } ], "minimum": 0.01, "maximum": 4280 } ] }, { "description": "IMPLANT CROSSLINK 75MM LUMBAR GCSDM", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3332, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1582.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1499.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1666 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1499.4 } ], "minimum": 0.01, "maximum": 1666 } ] }, { "description": "IMPLANT AXOGUARD NERVE CONNECTOR 5X15", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8560, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4066, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 3852 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4280 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 3852 } ], "minimum": 0.01, "maximum": 4280 } ] }, { "description": "IMPLANT NEUROCAP 4.0MM NERVE GUIDE BIOPR", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4275, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4050 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4050 } ], "minimum": 0.01, "maximum": 4500 } ] }, { "description": "IMPLANT NEUROCAP 5.0MM BIOPRO", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4275, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4050 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4050 } ], "minimum": 0.01, "maximum": 4500 } ] }, { "description": "IMPLANT NEUROLAC 3.0MM BIOPRO", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 4275, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 4050 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 4500 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 4050 } ], "minimum": 0.01, "maximum": 4500 } ] }, { "description": "SALINE FILLED LRG TESTICULAR PROSTHESIS", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11332, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 5382.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 5099.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 5666 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 5099.4 } ], "minimum": 0.01, "maximum": 5666 } ] }, { "description": "IMPLANT NEUROCAP 4.0MM NERVE GUIDE B", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 26000, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.01 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 12350, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 11700 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 13000 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 11700 } ], "minimum": 0.01, "maximum": 13000 } ] }, { "description": "BB BLOOD PROCESSING/STORAGE", "code_information": [ { "code": "P9016", "type": "HCPCS" }, { "code": "390", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 253.5, "discounted_cash": 328.46, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 202.06, "additional_payer_notes": "125% of the Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 161.65, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 182.85 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 192.98341 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 164.23, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 221.71, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 164.23, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.7183, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 158.42, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 120.4125, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 444.54, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 164.23, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 262.768, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 198.23, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 164.23, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 182 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 114.075 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 126.75 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 114.075 } ], "minimum": 114.075, "maximum": 444.54 } ] }, { "description": "BB RED BLOOD CELLS LEUKOREDUCED", "code_information": [ { "code": "P9016", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1060, "discounted_cash": 328.46, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 202.06, "additional_payer_notes": "125% of the Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 161.65, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 182.85 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 192.98341 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 164.23, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 221.71, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 164.23, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 198.7183, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 158.42, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 503.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 444.54, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 164.23, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 262.768, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 198.23, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 164.23, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 182 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 477 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 530 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 477 } ], "minimum": 158.42, "maximum": 530 } ] }, { "description": "BB PLATELETS PHERESIS LEUKOREDUC", "code_information": [ { "code": "P9035", "type": "HCPCS" }, { "code": "384", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2291.9, "discounted_cash": 908.74, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 540.78, "additional_payer_notes": "125% of the Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 432.62, "additional_payer_notes": "100%_of_Medicare_fee-schedule" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 485.02 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 511.900406 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 454.37, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 613.4, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 454.37, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 549.7877, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 423.97, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1088.6525, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "LWCC", "plan_name": "Workers Comp", "methodology": "fee schedule", "standard_charge_dollar": 1189.71, "additional_payer_notes": "275% of medicare fee schedule" }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 454.37, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 726.992, "additional_payer_notes": "160% of Medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 548.45, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 454.37, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 487.1 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1031.355 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1145.95 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1031.355 } ], "minimum": 423.97, "maximum": 1189.71 } ] }, { "description": "IMPLANT MESHED BILAYER WOUND MATRIX INTE", "code_information": [ { "code": "Q4104", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 22323.6, "discounted_cash": 225.84, "payers_information": [ { "payer_name": "Aetna", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 141.15, "additional_payer_notes": "125% of the Medicare fee schedule" }, { "payer_name": "Aetna", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 112.92, "additional_payer_notes": "100% of Medicare" }, { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 54.29 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 54.29 }, { "payer_name": "Blue Cross", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 112.92, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 152.442, "additional_payer_notes": "pays 135% of Medicare fee schedule" }, { "payer_name": "Coventry", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 112.92, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 136.6332, "additional_payer_notes": "121% of Medicare fee schedule" }, { "payer_name": "Humana", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 110.6616, "additional_payer_notes": "98% of medicare fee schedule" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 10603.71, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Peoples Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 112.92, "additional_payer_notes": "100% of medicare fee schedule" }, { "payer_name": "PPO Plus", "plan_name": "Commercial", "methodology": "fee schedule", "standard_charge_dollar": 180.672, "additional_payer_notes": "160% of medicare" }, { "payer_name": "United Health", "plan_name": "Commercial UMR", "methodology": "fee schedule", "standard_charge_dollar": 136.3, "additional_payer_notes": "medicare with $98 conv factor" }, { "payer_name": "United Health", "plan_name": "Medicare Advantage", "methodology": "fee schedule", "standard_charge_dollar": 112.92, "additional_payer_notes": "100% medicare fee schedule" }, { "payer_name": "TriWest", "plan_name": "TriWest", "methodology": "fee schedule", "standard_charge_dollar": 117.44 }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10045.62 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11161.8 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10045.62 } ], "minimum": 54.29, "maximum": 11161.8 } ] }, { "description": "IMPLANT CLARIX 100 AMNIOTIC MEMBRANE BIO", "code_information": [ { "code": "Q4155", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4800, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 28.94 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2280, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2160 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 2400 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2160 } ], "minimum": 28.94, "maximum": 2400 } ] }, { "description": "OMNISCAN 5ML VIAL GE HEALTHCARE", "code_information": [ { "code": "Q9967", "type": "HCPCS" }, { "code": "00407-0690-05", "type": "NDC" } ], "drug_information": { "unit": 5, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 6.2, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.14 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 2.945, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 2.79 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 3.1 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 2.79 } ], "minimum": 0.14, "maximum": 3.1 } ] }, { "description": "OMNISCAN 10ML VIAL GE HEALTHCARE", "code_information": [ { "code": "Q9967", "type": "HCPCS" }, { "code": "00407-0690-10", "type": "NDC" } ], "drug_information": { "unit": 10, "type": "ML" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 23.2, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.14 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 11.02, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 10.44 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 11.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 10.44 } ], "minimum": 0.14, "maximum": 11.6 } ] }, { "description": "OMNIPAQUE 240 50ML PER/ML", "code_information": [ { "code": "Q9967", "type": "HCPCS" }, { "code": "00407-1412-30", "type": "NDC" } ], "drug_information": { "unit": 240, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 0.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.14 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.2375, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.225 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.225 } ], "minimum": 0.14, "maximum": 0.25 } ] }, { "description": "OMNIPAQUE 240 100ML PER/ML", "code_information": [ { "code": "Q9967", "type": "HCPCS" }, { "code": "00407-1412-33", "type": "NDC" } ], "drug_information": { "unit": 240, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 0.44, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.14 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.209, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.198 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.22 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.198 } ], "minimum": 0.14, "maximum": 0.22 } ] }, { "description": "OMNIPAQUE 300 100ML PER/ML", "code_information": [ { "code": "Q9967", "type": "HCPCS" }, { "code": "00407-1413-63", "type": "NDC" } ], "drug_information": { "unit": 300, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 0.5, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.14 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.2375, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.225 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.25 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.225 } ], "minimum": 0.14, "maximum": 0.25 } ] }, { "description": "OMNIPAQUE 350 100ML PER/ML", "code_information": [ { "code": "Q9967", "type": "HCPCS" }, { "code": "00407-1414-91", "type": "NDC" } ], "drug_information": { "unit": 350, "type": "ME" }, "standard_charges": [ { "setting": "outpatient", "gross_charge": 1, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 0.14 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 0.14 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.475, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 0.45 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.5 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 0.45 } ], "minimum": 0.14, "maximum": 0.5 } ] }, { "description": "IMPLANT LENS TECNIS EYHANCE (DIB00)", "code_information": [ { "code": "V2632", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 877.2, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 115.32 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 121.712234 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 416.67, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 394.74 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 438.6 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 394.74 } ], "minimum": 115.32, "maximum": 438.6 } ] }, { "description": "IMPLANT LENS enVISTA ASPIRE B&L", "code_information": [ { "code": "V2632", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 122.4, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 115.32 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 121.712234 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 58.14, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 55.08 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 61.2 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 55.08 } ], "minimum": 55.08, "maximum": 121.712234 } ] }, { "description": "IMPLANT LENS ACRY SOFT IQ", "code_information": [ { "code": "V2632", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 612, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 115.32 }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 121.712234 }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 290.7, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 275.4 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 306 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 275.4 } ], "minimum": 115.32, "maximum": 306 } ] }, { "description": "IMPLANT CLAREON VIVITY TORIC", "code_information": [ { "code": "V2787", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3580, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 1790, "additional_payer_notes": "pays 50% of gross" }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 1790, "additional_payer_notes": "pays 50% of gross" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 1700.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 1611 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 1790 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 1611 } ], "minimum": 1611, "maximum": 1790 } ] }, { "description": "IMPLANT LENS enVISTA ASPRIE TORIC B&L", "code_information": [ { "code": "V2787", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1940, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 970, "additional_payer_notes": "pays 50% of gross" }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 970, "additional_payer_notes": "pays 50% of gross" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 921.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 873 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 970 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 873 } ], "minimum": 873, "maximum": 970 } ] }, { "description": "IMPLANT LENS TECNIS TORIS (ZTOR)", "code_information": [ { "code": "V2788", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1940, "payers_information": [ { "payer_name": "Blue Cross", "plan_name": "HMO", "methodology": "fee schedule", "standard_charge_dollar": 970, "additional_payer_notes": "pays 50% of gross" }, { "payer_name": "Blue Cross", "plan_name": "PPO Fed POS", "methodology": "fee schedule", "standard_charge_dollar": 970, "additional_payer_notes": "pays 50% of gross" }, { "payer_name": "LUBA", "plan_name": "Workers Comp", "methodology": "percent of total billed charges", "standard_charge_dollar": 921.5, "standard_charge_percentage": 47.5, "count": "0", "additional_payer_notes": "No remittance data was supplied in the source file for the required 12- to 15-month lookback period." }, { "payer_name": "Prove Partners", "plan_name": "Prove Partners", "methodology": "fee schedule", "standard_charge_dollar": 873 }, { "payer_name": "DMA Funding", "plan_name": "DMA Funding", "methodology": "fee schedule", "standard_charge_dollar": 970 }, { "payer_name": "HMR Funding", "plan_name": "HMR Funding", "methodology": "fee schedule", "standard_charge_dollar": 873 } ], "minimum": 873, "maximum": 970 } ] } ] }