{ "hospital_name": "SBH Colorado LLC", "last_updated_on": "2026-05-20", "version": "3.0.0", "location_name": [ "Peak View Behavioral Health" ], "hospital_address": [ "7353 Sisters Grove, Colorado Springs, CO 80923" ], "license_information": { "state": "CO", "license_number": "01O618" }, "type_2_npi": [ "1659524486", "1073118857" ], "attestation": { "attestation": "To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.", "confirm_attestation": true, "attester_name": "Ty Meredith" }, "standard_charge_information": [ { "description": "DBT Individual Therapy", "code_information": [ { "code": "90785", "type": "CPT" }, { "code": "630002", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "Amerigroup", "plan_name": "Amerigroup", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 80.0, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Alliance Health And Life", "plan_name": "Cigna Alliance Health And Life", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Health Spring Medicare Advantage", "plan_name": "Cigna Health Spring Medicare Advantage", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Supplemental", "plan_name": "Cigna Supplemental", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "Cigna True Choice Medicare PPO", "plan_name": "Cigna True Choice Medicare PPO", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Zenith Administrators", "plan_name": "Cigna Zenith Administrators", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 80.0, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "Optum Health Behavioral Solutions", "plan_name": "Optum Health Behavioral Solutions", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "Tufts Health Plan", "plan_name": "Tufts Health Plan", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "UPMC Health Plan", "plan_name": "UPMC Health Plan", "standard_charge_dollar": 75.0, "methodology": "fee schedule" } ], "minimum": 75.0, "maximum": 80.0 } ] }, { "description": "Tri/Medi Adult PHP ACT - 1 unit", "code_information": [ { "code": "G0176", "type": "HCPCS" }, { "code": "2041", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 435.6, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 227.92, "methodology": "fee schedule" } ], "minimum": 188.69, "maximum": 500.0 } ] }, { "description": "Tri/Medi Adult PHP ACT - 2 units", "code_information": [ { "code": "G0176", "type": "HCPCS" }, { "code": "2042", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 435.6, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 227.92, "methodology": "fee schedule" } ], "minimum": 188.69, "maximum": 500.0 } ] }, { "description": "Tri/Medi Adult PHP ACT - 3 units", "code_information": [ { "code": "G0176", "type": "HCPCS" }, { "code": "2043", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 435.6, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 227.92, "methodology": "fee schedule" } ], "minimum": 188.69, "maximum": 500.0 } ] }, { "description": "Tri/Medi Adult PHP ACT - 4 units", "code_information": [ { "code": "G0176", "type": "HCPCS" }, { "code": "2044", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 435.6, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 227.92, "methodology": "fee schedule" } ], "minimum": 188.69, "maximum": 500.0 } ] }, { "description": "Tri/Medi Adult PHP ACT - 5 units", "code_information": [ { "code": "G0176", "type": "HCPCS" }, { "code": "2045", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 435.6, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 227.92, "methodology": "fee schedule" } ], "minimum": 188.69, "maximum": 500.0 } ] }, { "description": "Acute Adult Detox 3.7", "code_information": [ { "code": "1000", "type": "RC" }, { "code": "110014", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Carelon Health Colorado Medicaid", "plan_name": "Carelon Health Colorado Medicaid", "standard_charge_dollar": 1050.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Northeast Health Partners Mcaid", "plan_name": "Carelon Northeast Health Partners Mcaid", "standard_charge_dollar": 1050.0, "methodology": "fee schedule" }, { "payer_name": "Colo Community Health Alliance", "plan_name": "Colo Community Health Alliance", "standard_charge_dollar": 689.61, "methodology": "fee schedule" }, { "payer_name": "Northeast HP- RMHP", "plan_name": "Northeast HP- RMHP", "standard_charge_dollar": 1050.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Health Plans Medicaid", "plan_name": "Rocky Mountain Health Plans Medicaid", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 2800.0, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "minimum": 689.61, "maximum": 2800.0 } ] }, { "description": "Acute Adult Detox", "code_information": [ { "code": "1002", "type": "RC" }, { "code": "110011", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 964.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Health Colorado Medicaid", "plan_name": "Carelon Health Colorado Medicaid", "standard_charge_dollar": 1050.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Northeast Health Partners Mcaid", "plan_name": "Carelon Northeast Health Partners Mcaid", "standard_charge_dollar": 1050.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 1088.0, "methodology": "fee schedule" }, { "payer_name": "Colo Community Health Alliance", "plan_name": "Colo Community Health Alliance", "standard_charge_dollar": 960.62, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 910.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access CHP+", "plan_name": "Colorado Access CHP+", "standard_charge_dollar": 910.0, "methodology": "fee schedule" }, { "payer_name": "Employers Health Network", "plan_name": "Employers Health Network", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Gravie Admin Service Aetna", "plan_name": "Gravie Admin Service Aetna", "standard_charge_dollar": 1140.0, "methodology": "fee schedule" }, { "payer_name": "HAP Aetna", "plan_name": "HAP Aetna", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp Integrated Solutions LLC", "plan_name": "HealthComp Integrated Solutions LLC", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Health Services", "plan_name": "Magellan Health Services", "standard_charge_dollar": 1060.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health- Aetna Choice POS", "plan_name": "Meritain Health- Aetna Choice POS", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Northeast HP- RMHP", "plan_name": "Northeast HP- RMHP", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Priority Health Insurance", "plan_name": "Priority Health Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Health Plans Medicaid", "plan_name": "Rocky Mountain Health Plans Medicaid", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Simplan Insurance", "plan_name": "Simplan Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 2800.0, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "minimum": 900.0, "maximum": 2800.0 } ] }, { "description": "Acute Gero Detox", "code_information": [ { "code": "1002", "type": "RC" }, { "code": "110012", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 964.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Health Colorado Medicaid", "plan_name": "Carelon Health Colorado Medicaid", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Northeast Health Partners Mcaid", "plan_name": "Carelon Northeast Health Partners Mcaid", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Colo Community Health Alliance", "plan_name": "Colo Community Health Alliance", "standard_charge_dollar": 960.62, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 910.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access CHP+", "plan_name": "Colorado Access CHP+", "standard_charge_dollar": 910.0, "methodology": "fee schedule" }, { "payer_name": "Employers Health Network", "plan_name": "Employers Health Network", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Gravie Admin Service Aetna", "plan_name": "Gravie Admin Service Aetna", "standard_charge_dollar": 1140.0, "methodology": "fee schedule" }, { "payer_name": "HAP Aetna", "plan_name": "HAP Aetna", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp Integrated Solutions LLC", "plan_name": "HealthComp Integrated Solutions LLC", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health- Aetna Choice POS", "plan_name": "Meritain Health- Aetna Choice POS", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Northeast HP- RMHP", "plan_name": "Northeast HP- RMHP", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Priority Health Insurance", "plan_name": "Priority Health Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Health Plans Medicaid", "plan_name": "Rocky Mountain Health Plans Medicaid", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Simplan Insurance", "plan_name": "Simplan Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 2800.0, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "minimum": 900.0, "maximum": 2800.0 } ] }, { "description": "LOA Adult", "code_information": [ { "code": "101000", "type": "RC" }, { "code": "101000", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 780.0, "methodology": "fee schedule" } ], "minimum": 780.0, "maximum": 780.0 } ] }, { "description": "Low Functioning", "code_information": [ { "code": "102000", "type": "RC" }, { "code": "102000", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "AARP Health Care Options", "plan_name": "AARP Health Care Options", "standard_charge_dollar": 780.0, "methodology": "fee schedule" }, { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal 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"standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Equitable Life And Casualty Insurance Co", "plan_name": "Equitable Life And Casualty Insurance Co", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Equitable Plan Services", "plan_name": "Equitable Plan Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Evercare - Medicaid New Mexico", "plan_name": "Evercare - Medicaid New Mexico", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Friday Health Plans", "plan_name": "Friday Health Plans", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Harvard Pilgrim HealthCare", "plan_name": "Harvard Pilgrim HealthCare", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Commercial Claims", "plan_name": "Health Net Commercial Claims", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Hemet Community Medical Group", "plan_name": "Hemet Community Medical Group", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "HWBS Claims", "plan_name": "HWBS Claims", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente", "plan_name": 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"Meritain Health", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "MERP Administrative Services", "plan_name": "MERP Administrative Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "MHNET", "plan_name": "MHNET", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "Mines And Associates, PC", "plan_name": "Mines And Associates, PC", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Mitchell International", "plan_name": "Mitchell International", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "MVP Healthcare Value Opts", "plan_name": "MVP Healthcare Value Opts", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "NALC Health Benefit Plan", "plan_name": "NALC Health Benefit Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Nationwide Life", "plan_name": "Nationwide Life", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Neighborhood Health Plan", "plan_name": "Neighborhood Health Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Network Health VA", "plan_name": "Network Health VA", "standard_charge_dollar": 579.6, "methodology": "fee schedule" }, { "payer_name": "OPTUM EMPIRE HEALTH PLAN", "plan_name": "OPTUM EMPIRE HEALTH PLAN", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Pacificare Behavioral Health", "plan_name": "Pacificare Behavioral Health", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Penrose Hospital", "plan_name": "Penrose Hospital", "standard_charge_dollar": 750.0, "methodology": "fee 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"Reserve Officers Assoc Insurance", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "RMHP HMO Optum", "plan_name": "RMHP HMO Optum", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "RMSCO, Inc", "plan_name": "RMSCO, Inc", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Pace", "plan_name": "Rocky Mountain Pace", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain-Life Strategies", "plan_name": "Rocky Mountain-Life Strategies", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "SECURE HORIZONS", "plan_name": "SECURE HORIZONS", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons (Medicare)", "plan_name": "Secure Horizons (Medicare)", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons Direct", "plan_name": "Secure Horizons Direct", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Select Benefits Administrators", "plan_name": "Select Benefits Administrators", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Selman Co", "plan_name": "Selman Co", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Sentinel Life Insurance", "plan_name": "Sentinel Life Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sharp Community Med Grp/Secure Horizon", "plan_name": "Sharp Community Med Grp/Secure Horizon", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sheet Metal Workers", "plan_name": "Sheet Metal Workers", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "Standard Life And Accident Insurance", "plan_name": "Standard Life And Accident Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "The GEMGroup", "plan_name": "The GEMGroup", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Total Long Term Care", "plan_name": "Total Long Term Care", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "Total Longterm Care INC", "plan_name": "Total Longterm Care INC", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "Travelers Insurance", "plan_name": "Travelers Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 988.0, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 988.0, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 988.0, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 988.0, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 964.25, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "UMR/CEBT-PM085516", "plan_name": "UMR/CEBT-PM085516", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "UPMC Health Plan", "plan_name": "UPMC Health Plan", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "WEBB TPA", "plan_name": "WEBB TPA", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Winhealth", "plan_name": "Winhealth", "standard_charge_dollar": 800.0, "methodology": "fee schedule" } ], "minimum": 579.6, "maximum": 1200.0 } ] }, { "description": "High Functioning Gero", "code_information": [ { "code": "103000", "type": "RC" }, { "code": "103000", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "AARP Health Care Options", "plan_name": "AARP Health Care Options", "standard_charge_dollar": 780.0, "methodology": "fee schedule" }, { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", 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"methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access CHP+", "plan_name": "Colorado Access CHP+", "standard_charge_dollar": 593.66, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Equitable Life And Casualty Insurance Co", "plan_name": "Equitable Life And Casualty Insurance Co", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Equitable Plan Services", "plan_name": "Equitable Plan Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Evercare - Medicaid New Mexico", "plan_name": "Evercare - Medicaid New Mexico", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Friday Health Plans", "plan_name": "Friday Health Plans", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Harvard Pilgrim HealthCare", "plan_name": "Harvard Pilgrim HealthCare", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Commercial Claims", "plan_name": "Health Net Commercial Claims", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Hemet Community Medical Group", "plan_name": "Hemet Community Medical Group", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "HWBS Claims", "plan_name": "HWBS Claims", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente", "plan_name": 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"standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Health Services", "plan_name": "Magellan Health Services", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Mailhandlers", "plan_name": "Mailhandlers", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Network Group", "plan_name": "Managed Health Network Group", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "MERP Administrative Services", "plan_name": "MERP Administrative Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "MHNET", "plan_name": "MHNET", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "Mines And Associates, PC", "plan_name": "Mines And Associates, PC", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Mitchell International", "plan_name": "Mitchell International", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "MVP Healthcare Value Opts", "plan_name": "MVP Healthcare Value Opts", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "NALC Health Benefit Plan", "plan_name": "NALC Health Benefit Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Nationwide Life", "plan_name": "Nationwide Life", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Neighborhood Health Plan", "plan_name": "Neighborhood Health Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Network Health VA", "plan_name": "Network Health VA", "standard_charge_dollar": 579.6, "methodology": "fee schedule" }, { "payer_name": "OPTUM EMPIRE HEALTH PLAN", "plan_name": "OPTUM EMPIRE HEALTH PLAN", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Pacificare Behavioral Health", "plan_name": "Pacificare Behavioral Health", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Penrose Hospital", "plan_name": "Penrose Hospital", "standard_charge_dollar": 750.0, "methodology": "fee schedule" }, { "payer_name": "Physicians Mutual Insurance Company", "plan_name": "Physicians Mutual Insurance Company", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "Pinnacol Assurance", "plan_name": "Pinnacol Assurance", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Preferred One Administrative Services", "plan_name": "Preferred One Administrative Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Presbyterian Health Plan", "plan_name": "Presbyterian Health Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Private Health Care Systems", "plan_name": "Private Health Care Systems", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Psych Care", "plan_name": "Psych Care", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Reserve Officers Assoc Insurance", "plan_name": "Reserve Officers Assoc Insurance", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "RMHP HMO Optum", "plan_name": "RMHP HMO Optum", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "RMSCO, Inc", "plan_name": "RMSCO, Inc", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Pace", "plan_name": "Rocky Mountain Pace", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain-Life Strategies", "plan_name": "Rocky Mountain-Life Strategies", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "SECURE HORIZONS", "plan_name": "SECURE HORIZONS", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons (Medicare)", "plan_name": "Secure Horizons (Medicare)", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons Direct", "plan_name": "Secure Horizons Direct", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Select Benefits Administrators", "plan_name": "Select Benefits Administrators", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Selman Co", "plan_name": "Selman Co", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Sentinel Life Insurance", "plan_name": "Sentinel Life Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sharp Community Med Grp/Secure Horizon", "plan_name": "Sharp Community Med Grp/Secure Horizon", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sheet Metal Workers", "plan_name": "Sheet Metal Workers", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "Standard Life And Accident Insurance", "plan_name": "Standard Life And Accident Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "The GEMGroup", "plan_name": "The GEMGroup", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Total Long Term Care", "plan_name": "Total Long Term Care", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "Total Longterm Care INC", "plan_name": "Total Longterm Care INC", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "Travelers Insurance", "plan_name": "Travelers Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 988.0, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 988.0, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 988.0, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 988.0, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 964.25, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "UMR/CEBT-PM085516", "plan_name": "UMR/CEBT-PM085516", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "UPMC Health Plan", "plan_name": "UPMC Health Plan", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "WEBB TPA", "plan_name": "WEBB TPA", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Winhealth", "plan_name": "Winhealth", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Wyoming Pace", "plan_name": "Wyoming Pace", "standard_charge_dollar": 800.0, "methodology": "fee schedule" } ], "minimum": 579.6, "maximum": 1200.0 } ] }, { "description": "IP Acute Adult", "code_information": [ { "code": "103100", "type": "RC" }, { "code": "103100", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "AARP Health Care Options", "plan_name": "AARP Health Care Options", "standard_charge_dollar": 780.0, "methodology": "fee schedule" }, { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Arapahoe County Dept Of Human Services", "plan_name": "Arapahoe County Dept Of Human Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health Strategies", "plan_name": "Carelon Behavioral Health Strategies", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH APWU", "plan_name": "Carelon BH APWU", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Employee Asst", "plan_name": "Carelon BH Employee Asst", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Great West", "plan_name": "Carelon BH Great West", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access CHP+", "plan_name": "Colorado Access CHP+", "standard_charge_dollar": 593.66, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Equitable Life And Casualty Insurance Co", "plan_name": "Equitable Life And Casualty Insurance Co", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Equitable Plan Services", "plan_name": "Equitable Plan Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Evercare - Medicaid New Mexico", "plan_name": "Evercare - Medicaid New Mexico", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Friday Health Plans", "plan_name": "Friday Health Plans", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Harvard Pilgrim HealthCare", "plan_name": "Harvard Pilgrim HealthCare", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Commercial Claims", "plan_name": "Health Net Commercial Claims", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Hemet Community Medical Group", "plan_name": "Hemet Community Medical Group", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "HWBS Claims", "plan_name": "HWBS Claims", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente", "plan_name": "Kaiser Permanente", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Denver", "plan_name": "Kaiser Permanente Denver", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Northern", "plan_name": "Kaiser Permanente Northern", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Senior Advantage HMO", "plan_name": "Kaiser Permanente Senior Advantage HMO", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente/KPIC", "plan_name": "Kaiser Permanente/KPIC", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "LINECO Mental Health & Substance Abuse", "plan_name": "LINECO Mental Health & Substance Abuse", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "M-Care Medical Network", "plan_name": "M-Care Medical Network", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Health Services", "plan_name": "Magellan Health Services", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Mailhandlers", "plan_name": "Mailhandlers", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Network Group", "plan_name": "Managed Health Network Group", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "MERP Administrative Services", "plan_name": "MERP Administrative Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "MHNET", "plan_name": "MHNET", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "Mines And Associates, PC", "plan_name": "Mines And Associates, PC", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Mitchell International", "plan_name": "Mitchell International", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "MVP Healthcare Value Opts", "plan_name": "MVP Healthcare Value Opts", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "NALC Health Benefit Plan", "plan_name": "NALC Health Benefit Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Nationwide Life", "plan_name": "Nationwide Life", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Neighborhood Health Plan", "plan_name": "Neighborhood Health Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Network Health VA", "plan_name": "Network Health VA", "standard_charge_dollar": 579.6, "methodology": "fee schedule" }, { "payer_name": "OPTUM EMPIRE HEALTH PLAN", "plan_name": "OPTUM EMPIRE HEALTH PLAN", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Pacificare Behavioral Health", "plan_name": "Pacificare Behavioral Health", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Penrose Hospital", "plan_name": "Penrose Hospital", "standard_charge_dollar": 750.0, "methodology": "fee schedule" }, { "payer_name": "Physicians Mutual Insurance Company", "plan_name": "Physicians Mutual Insurance Company", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "Pinnacol Assurance", "plan_name": "Pinnacol Assurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Preferred One Administrative Services", "plan_name": "Preferred One Administrative Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Presbyterian Health Plan", "plan_name": "Presbyterian Health Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Private Health Care Systems", "plan_name": "Private Health Care Systems", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Psych Care", "plan_name": "Psych Care", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Reserve Officers Assoc Insurance", "plan_name": "Reserve Officers Assoc Insurance", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "RMHP HMO Optum", "plan_name": "RMHP HMO Optum", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "RMSCO, Inc", "plan_name": "RMSCO, Inc", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Pace", "plan_name": "Rocky Mountain Pace", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain-Life Strategies", "plan_name": "Rocky Mountain-Life Strategies", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "SECURE HORIZONS", "plan_name": "SECURE HORIZONS", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons (Medicare)", "plan_name": "Secure Horizons (Medicare)", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons Direct", "plan_name": "Secure Horizons Direct", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Select Benefits Administrators", "plan_name": "Select Benefits Administrators", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Selman Co", "plan_name": "Selman Co", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Sentinel Life Insurance", "plan_name": "Sentinel Life Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sharp Community Med Grp/Secure Horizon", "plan_name": "Sharp Community Med Grp/Secure Horizon", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sheet Metal Workers", "plan_name": "Sheet Metal Workers", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "Standard Life And Accident Insurance", "plan_name": "Standard Life And Accident Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "The GEMGroup", "plan_name": "The GEMGroup", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Total Long Term Care", "plan_name": "Total Long Term Care", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "Total Longterm Care INC", "plan_name": "Total Longterm Care INC", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "Travelers Insurance", "plan_name": "Travelers Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 988.0, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 988.0, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 988.0, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 988.0, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 988.0, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 964.25, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "UMR/CEBT-PM085516", "plan_name": "UMR/CEBT-PM085516", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "UPMC Health Plan", "plan_name": "UPMC Health Plan", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "WEBB TPA", "plan_name": "WEBB TPA", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Winhealth", "plan_name": "Winhealth", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Wyoming Pace", "plan_name": "Wyoming Pace", "standard_charge_dollar": 800.0, "methodology": "fee schedule" } ], "minimum": 579.6, "maximum": 1200.0 } ] }, { "description": "IP Acute Child/Adol", "code_information": [ { "code": "103200", "type": "RC" }, { "code": "103200", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "AARP Health Care Options", "plan_name": "AARP Health Care Options", "standard_charge_dollar": 780.0, "methodology": "fee schedule" }, { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Arapahoe County Dept Of Human Services", "plan_name": "Arapahoe County Dept Of Human Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 936.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health Strategies", "plan_name": "Carelon Behavioral Health Strategies", "standard_charge_dollar": 936.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH APWU", "plan_name": "Carelon BH APWU", "standard_charge_dollar": 936.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Employee Asst", "plan_name": "Carelon BH Employee Asst", "standard_charge_dollar": 936.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Great West", "plan_name": "Carelon BH Great West", "standard_charge_dollar": 936.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 936.0, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access CHP+", "plan_name": "Colorado Access CHP+", "standard_charge_dollar": 593.66, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Equitable Life And Casualty Insurance Co", "plan_name": "Equitable Life And Casualty Insurance Co", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Equitable Plan Services", "plan_name": "Equitable Plan Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Friday Health Plans", "plan_name": "Friday Health Plans", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Harvard Pilgrim HealthCare", "plan_name": "Harvard Pilgrim HealthCare", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Commercial Claims", "plan_name": "Health Net Commercial Claims", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Hemet Community Medical Group", "plan_name": "Hemet Community Medical Group", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "HWBS Claims", "plan_name": "HWBS Claims", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente", "plan_name": "Kaiser Permanente", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Denver", "plan_name": "Kaiser Permanente Denver", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Northern", "plan_name": "Kaiser Permanente Northern", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente/KPIC", "plan_name": "Kaiser Permanente/KPIC", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "LINECO Mental Health & Substance Abuse", "plan_name": "LINECO Mental Health & Substance Abuse", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "M-Care Medical Network", "plan_name": "M-Care Medical Network", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Health Services", "plan_name": "Magellan Health Services", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Mailhandlers", "plan_name": "Mailhandlers", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Network Group", "plan_name": "Managed Health Network Group", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "MERP Administrative Services", "plan_name": "MERP Administrative Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "MHNET", "plan_name": "MHNET", "standard_charge_dollar": 936.0, "methodology": "fee schedule" }, { "payer_name": "Mines And Associates, PC", "plan_name": "Mines And Associates, PC", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Mitchell International", "plan_name": "Mitchell International", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "MVP Healthcare Value Opts", "plan_name": "MVP Healthcare Value Opts", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "NALC Health Benefit Plan", "plan_name": "NALC Health Benefit Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Nationwide Life", "plan_name": "Nationwide Life", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Neighborhood Health Plan", "plan_name": "Neighborhood Health Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Network Health VA", "plan_name": "Network Health VA", "standard_charge_dollar": 579.6, "methodology": "fee schedule" }, { "payer_name": "OPTUM EMPIRE HEALTH PLAN", "plan_name": "OPTUM EMPIRE HEALTH PLAN", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Penrose Hospital", "plan_name": "Penrose Hospital", "standard_charge_dollar": 750.0, "methodology": "fee schedule" }, { "payer_name": "Physicians Mutual Insurance Company", "plan_name": "Physicians Mutual Insurance Company", "standard_charge_dollar": 936.0, "methodology": "fee schedule" }, { "payer_name": "Pinnacol Assurance", "plan_name": "Pinnacol Assurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Preferred One Administrative Services", "plan_name": "Preferred One Administrative Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Presbyterian Health Plan", "plan_name": "Presbyterian Health Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Private Health Care Systems", "plan_name": "Private Health Care Systems", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Psych Care", "plan_name": "Psych Care", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Reserve Officers Assoc Insurance", "plan_name": "Reserve Officers Assoc Insurance", "standard_charge_dollar": 936.0, "methodology": "fee schedule" }, { "payer_name": "RMHP HMO Optum", "plan_name": "RMHP HMO Optum", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "RMSCO, Inc", "plan_name": "RMSCO, Inc", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain-Life Strategies", "plan_name": "Rocky Mountain-Life Strategies", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "SECURE HORIZONS", "plan_name": "SECURE HORIZONS", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Select Benefits Administrators", "plan_name": "Select Benefits Administrators", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Selman Co", "plan_name": "Selman Co", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Sentinel Life Insurance", "plan_name": "Sentinel Life Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sheet Metal Workers", "plan_name": "Sheet Metal Workers", "standard_charge_dollar": 936.0, "methodology": "fee schedule" }, { "payer_name": "Standard Life And Accident Insurance", "plan_name": "Standard Life And Accident Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "The GEMGroup", "plan_name": "The GEMGroup", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Total Long Term Care", "plan_name": "Total Long Term Care", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "Total Longterm Care INC", "plan_name": "Total Longterm Care INC", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Travelers Insurance", "plan_name": "Travelers Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 988.0, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 988.0, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 988.0, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 988.0, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 988.0, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 964.25, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "UMR/CEBT-PM085516", "plan_name": "UMR/CEBT-PM085516", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "UPMC Health Plan", "plan_name": "UPMC Health Plan", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "WEBB TPA", "plan_name": "WEBB TPA", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Winhealth", "plan_name": "Winhealth", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Wyoming Pace", "plan_name": "Wyoming Pace", "standard_charge_dollar": 800.0, "methodology": "fee schedule" } ], "minimum": 579.6, "maximum": 1200.0 } ] }, { "description": "Acute Adol Detox", "code_information": [ { "code": "110006", "type": "RC" }, { "code": "110006", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 1342.0, "methodology": "fee schedule" }, { "payer_name": "Allied Benefits Systems", "plan_name": "Allied Benefits Systems", "standard_charge_dollar": 1092.0, "methodology": "fee schedule" }, { "payer_name": "Allsavers", "plan_name": "Allsavers", "standard_charge_dollar": 1014.0, "methodology": "fee 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"standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "ASI Tricare Retired Supplement", "plan_name": "ASI Tricare Retired Supplement", "standard_charge_dollar": 1156.0, "methodology": "fee schedule" }, { "payer_name": "Bankers Fidelity", "plan_name": "Bankers Fidelity", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Baylor Scott & White", "plan_name": "Baylor Scott & White", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "Bind Benefits, Inc", "plan_name": "Bind Benefits, Inc", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Bright Health Management", "plan_name": "Bright Health Management", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 1032.64, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health Strategies", "plan_name": "Carelon Behavioral Health Strategies", "standard_charge_dollar": 1032.64, "methodology": "fee schedule" }, { "payer_name": "Carelon BH APWU", "plan_name": "Carelon BH APWU", "standard_charge_dollar": 1032.64, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Employee Asst", "plan_name": "Carelon BH Employee Asst", "standard_charge_dollar": 1032.64, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Great West", "plan_name": "Carelon BH Great West", "standard_charge_dollar": 1032.64, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 1032.64, "methodology": "fee schedule" }, { "payer_name": "Carelon Health Colorado Medicaid", "plan_name": "Carelon Health Colorado Medicaid", "standard_charge_dollar": 939.62, "methodology": "fee schedule" }, { "payer_name": "Carelon Medicare Advantage", "plan_name": "Carelon Medicare Advantage", "standard_charge_dollar": 1032.64, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 1034.0, "methodology": "fee schedule" }, { "payer_name": "ComPsych", "plan_name": "ComPsych", "standard_charge_dollar": 1069.0, "methodology": "fee schedule" }, { "payer_name": "Continental Insurance - Marpai Health", "plan_name": "Continental Insurance - Marpai Health", "standard_charge_dollar": 1034.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health DHHA", "plan_name": "Denver Health DHHA", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Elevate Silver", "plan_name": "Denver Health Elevate Silver", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Med Plan Cofinity", "plan_name": "Denver Health Med Plan Cofinity", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "Diversus Health", "plan_name": "Diversus Health", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Employers Health Network", "plan_name": "Employers Health Network", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Enterprise Group Planning, Inc", "plan_name": "Enterprise Group Planning, Inc", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "Federal Blue Cross", "plan_name": "Federal Blue Cross", "standard_charge_dollar": 1125.0, "methodology": "fee schedule" }, { "payer_name": "First Choice Health Network", "plan_name": "First Choice Health Network", "standard_charge_dollar": 1004.0, "methodology": "fee schedule" }, { "payer_name": "Friday Health Plans", "plan_name": "Friday Health Plans", "standard_charge_dollar": 1025.0, "methodology": "fee schedule" }, { "payer_name": "Fringe Benefit Group", "plan_name": "Fringe Benefit Group", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "Gravie Admin Service Aetna", "plan_name": "Gravie Admin Service Aetna", "standard_charge_dollar": 1140.0, "methodology": "fee schedule" }, { "payer_name": "HAP Aetna", "plan_name": "HAP Aetna", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "HCA Optum", "plan_name": "HCA Optum", "standard_charge_dollar": 920.0, "methodology": "fee schedule" }, { "payer_name": "Health Alliance", "plan_name": "Health Alliance", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp Integrated Solutions LLC", "plan_name": "HealthComp Integrated Solutions LLC", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope", "plan_name": "HealthScope", "standard_charge_dollar": 1034.0, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 1480.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 990.0, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Humana Tricare East", "plan_name": "Humana Tricare East", "standard_charge_dollar": 1156.0, "methodology": "fee schedule" }, { "payer_name": "Huntsman Mental Health Institute - BHN", "plan_name": "Huntsman Mental Health Institute - BHN", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Imagine 360 Administrators", "plan_name": "Imagine 360 Administrators", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Of Georgia", "plan_name": "Kaiser Of Georgia", "standard_charge_dollar": 1194.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Denver", "plan_name": "Kaiser Permanente Denver", "standard_charge_dollar": 1218.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanete Of Harrington", "plan_name": "Kaiser Permanete Of Harrington", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Liberty Healthshare", "plan_name": "Liberty Healthshare", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "Lucent Health", "plan_name": "Lucent Health", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Devoted Health Plans", "plan_name": "Magellan Devoted Health Plans", "standard_charge_dollar": 1060.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Health Services", "plan_name": "Magellan Health Services", "standard_charge_dollar": 1060.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Insurance", "plan_name": "Magellan Insurance", "standard_charge_dollar": 1060.0, "methodology": "fee schedule" }, { "payer_name": "MBA Tricare Supplemental", "plan_name": "MBA Tricare Supplemental", "standard_charge_dollar": 1156.0, "methodology": "fee schedule" }, { "payer_name": "Medica Elect", "plan_name": "Medica Elect", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 1140.3, "methodology": "fee schedule" }, { "payer_name": "Meritain Health- Aetna Choice POS", "plan_name": "Meritain Health- Aetna Choice POS", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Mines And Associates, PC", "plan_name": "Mines And Associates, PC", "standard_charge_dollar": 1600.0, "methodology": "fee schedule" }, { "payer_name": "Motivhealth", "plan_name": "Motivhealth", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Mountain Health Co-op", "plan_name": "Mountain Health Co-op", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "Multiplan", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "Pacific Source Health Plan", "plan_name": "Pacific Source Health Plan", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "ParkCare Plus", "plan_name": "ParkCare Plus", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Priority Health Insurance", "plan_name": "Priority Health Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Provider Network Of America", "plan_name": "Provider Network Of America", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Redirect Health - Multiplan", "plan_name": "Redirect Health - Multiplan", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "RMHP Commercial Optun", "plan_name": "RMHP Commercial Optun", "standard_charge_dollar": 1066.05, "methodology": "fee schedule" }, { "payer_name": "RMHP HMO Optum", "plan_name": "RMHP HMO Optum", "standard_charge_dollar": 1066.05, "methodology": "fee schedule" }, { "payer_name": "Routt County Jail & Detention Center", "plan_name": "Routt County Jail & Detention Center", "standard_charge_dollar": 1500.0, "methodology": "fee schedule" }, { "payer_name": "Sanford Health Ins - Multiplan", "plan_name": "Sanford Health Ins - Multiplan", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Insurance", "plan_name": "Select Health Insurance", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Medicare Adv", "plan_name": "Select Health Medicare Adv", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 859.0, "methodology": "fee schedule" }, { "payer_name": "Shelter Point", "plan_name": "Shelter Point", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Simplan Insurance", "plan_name": "Simplan Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "State Of Co Probation", "plan_name": "State Of Co Probation", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Surest - United Health Care", "plan_name": "Surest - United Health Care", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "TLC Benefits Solution Inc.", "plan_name": "TLC Benefits Solution Inc.", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 1156.0, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 1156.0, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 1156.0, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 1156.0, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 1156.0, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 1156.0, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 1156.0, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 1480.0, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 1004.0, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care New Mexico", "plan_name": "United Health Care New Mexico", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Student Resources", "plan_name": "United Healthcare Student Resources", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Supplement", "plan_name": "United Healthcare Supplement", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "United Select Health", "plan_name": "United Select Health", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "United World Life", "plan_name": "United World Life", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "Wellfleet", "plan_name": "Wellfleet", "standard_charge_dollar": 950.0, "methodology": "fee schedule" } ], "minimum": 859.0, "maximum": 1600.0 } ] }, { "description": "Gero CD Rehab", "code_information": [ { "code": "110007", "type": "RC" }, { "code": "110007", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 1342.0, "methodology": "fee schedule" }, { "payer_name": "Allsavers", "plan_name": "Allsavers", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "American Republic Corp Ins", "plan_name": "American Republic Corp Ins", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "AMFirst", "plan_name": "AMFirst", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 980.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "ASI Tricare Retired Supplement", "plan_name": "ASI Tricare Retired Supplement", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Baylor Scott & White", "plan_name": "Baylor Scott & White", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Bind Benefits, Inc", "plan_name": "Bind Benefits, Inc", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 803.4, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health Strategies", "plan_name": "Carelon Behavioral Health Strategies", "standard_charge_dollar": 803.4, "methodology": "fee schedule" }, { "payer_name": "Carelon BH APWU", "plan_name": "Carelon BH APWU", "standard_charge_dollar": 803.4, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Employee Asst", "plan_name": "Carelon BH Employee Asst", "standard_charge_dollar": 803.4, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Great West", "plan_name": "Carelon BH Great West", "standard_charge_dollar": 803.4, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 964.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 1034.0, "methodology": "fee schedule" }, { "payer_name": "ComPsych", "plan_name": "ComPsych", "standard_charge_dollar": 1040.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health DHHA", "plan_name": "Denver Health DHHA", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Elevate Silver", "plan_name": "Denver Health Elevate Silver", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Med Plan Cofinity", "plan_name": "Denver Health Med Plan Cofinity", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Employers Health Network", "plan_name": "Employers Health Network", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Enterprise Group Planning, Inc", "plan_name": "Enterprise Group Planning, Inc", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "First Choice Health Network", "plan_name": "First Choice Health Network", "standard_charge_dollar": 1004.0, "methodology": "fee schedule" }, { "payer_name": "Friday Health Plans", "plan_name": "Friday Health Plans", "standard_charge_dollar": 941.0, "methodology": "fee schedule" }, { "payer_name": "Fringe Benefit Group", "plan_name": "Fringe Benefit Group", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Gravie Admin Service Aetna", "plan_name": "Gravie Admin Service Aetna", "standard_charge_dollar": 1140.0, "methodology": "fee schedule" }, { "payer_name": "HAP Aetna", "plan_name": "HAP Aetna", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "HCA Optum", "plan_name": "HCA Optum", "standard_charge_dollar": 863.0, "methodology": "fee schedule" }, { "payer_name": "Health Alliance", "plan_name": "Health Alliance", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp Integrated Solutions LLC", "plan_name": "HealthComp Integrated Solutions LLC", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope", "plan_name": "HealthScope", "standard_charge_dollar": 1034.0, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 1480.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 980.0, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 980.0, "methodology": "fee schedule" }, { "payer_name": "Humana Tricare East", "plan_name": "Humana Tricare East", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Huntsman Mental Health Institute - BHN", "plan_name": "Huntsman Mental Health Institute - BHN", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Imagine 360 Administrators", "plan_name": "Imagine 360 Administrators", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Liberty Healthshare", "plan_name": "Liberty Healthshare", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Devoted Health Plans", "plan_name": "Magellan Devoted Health Plans", "standard_charge_dollar": 1060.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Health Services", "plan_name": "Magellan Health Services", "standard_charge_dollar": 1060.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Insurance", "plan_name": "Magellan Insurance", "standard_charge_dollar": 1060.0, "methodology": "fee schedule" }, { "payer_name": "MBA Tricare Supplemental", "plan_name": "MBA Tricare Supplemental", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Medica Elect", "plan_name": "Medica Elect", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 1140.3, "methodology": "fee schedule" }, { "payer_name": "Meritain Health- Aetna Choice POS", "plan_name": "Meritain Health- Aetna Choice POS", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Motivhealth", "plan_name": "Motivhealth", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Mountain Health Co-op", "plan_name": "Mountain Health Co-op", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Priority Health Insurance", "plan_name": "Priority Health Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Provider Network Of America", "plan_name": "Provider Network Of America", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "RMHP Commercial Optun", "plan_name": "RMHP Commercial Optun", "standard_charge_dollar": 1066.05, "methodology": "fee schedule" }, { "payer_name": "RMHP HMO Optum", "plan_name": "RMHP HMO Optum", "standard_charge_dollar": 1066.05, "methodology": "fee schedule" }, { "payer_name": "Routt County Jail & Detention Center", "plan_name": "Routt County Jail & Detention Center", "standard_charge_dollar": 1500.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Insurance", "plan_name": "Select Health Insurance", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Medicare Adv", "plan_name": "Select Health Medicare Adv", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 806.0, "methodology": "fee schedule" }, { "payer_name": "Shelter Point", "plan_name": "Shelter Point", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Simplan Insurance", "plan_name": "Simplan Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "State Of Co Probation", "plan_name": "State Of Co Probation", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Surest - United Health Care", "plan_name": "Surest - United Health Care", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "TLC Benefits Solution Inc.", "plan_name": "TLC Benefits Solution Inc.", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 1480.0, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 1004.0, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care New Mexico", "plan_name": "United Health Care New Mexico", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Student Resources", "plan_name": "United Healthcare Student Resources", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Supplement", "plan_name": "United Healthcare Supplement", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Select Health", "plan_name": "United Select Health", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United World Life", "plan_name": "United World Life", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" } ], "minimum": 803.4, "maximum": 1500.0 } ] }, { "description": "Adult CD Rehab", "code_information": [ { "code": "110008", "type": "RC" }, { "code": "110008", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 1342.0, "methodology": "fee schedule" }, { "payer_name": "Allsavers", "plan_name": "Allsavers", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "American Republic Corp Ins", "plan_name": "American Republic Corp Ins", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "AMFirst", "plan_name": "AMFirst", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 980.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "ASI Tricare Retired Supplement", "plan_name": "ASI Tricare Retired Supplement", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Baylor Scott & White", "plan_name": "Baylor Scott & White", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Bind Benefits, Inc", "plan_name": "Bind Benefits, Inc", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 803.04, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health Strategies", "plan_name": "Carelon Behavioral Health Strategies", "standard_charge_dollar": 803.04, "methodology": "fee schedule" }, { "payer_name": "Carelon BH APWU", "plan_name": "Carelon BH APWU", "standard_charge_dollar": 803.04, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Employee Asst", "plan_name": "Carelon BH Employee Asst", "standard_charge_dollar": 803.04, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Great West", "plan_name": "Carelon BH Great West", "standard_charge_dollar": 803.04, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 964.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 1034.0, "methodology": "fee schedule" }, { "payer_name": "ComPsych", "plan_name": "ComPsych", "standard_charge_dollar": 1040.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health DHHA", "plan_name": "Denver Health DHHA", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Elevate Silver", "plan_name": "Denver Health Elevate Silver", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Med Plan Cofinity", "plan_name": "Denver Health Med Plan Cofinity", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Employers Health Network", "plan_name": "Employers Health Network", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Enterprise Group Planning, Inc", "plan_name": "Enterprise Group Planning, Inc", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "First Choice Health Network", "plan_name": "First Choice Health Network", "standard_charge_dollar": 1004.0, "methodology": "fee schedule" }, { "payer_name": "Friday Health Plans", "plan_name": "Friday Health Plans", "standard_charge_dollar": 941.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Gravie Admin Service Aetna", "plan_name": "Gravie Admin Service Aetna", "standard_charge_dollar": 1140.0, "methodology": "fee schedule" }, { "payer_name": "HAP Aetna", "plan_name": "HAP Aetna", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "HCA Optum", "plan_name": "HCA Optum", "standard_charge_dollar": 863.0, "methodology": "fee schedule" }, { "payer_name": "Health Alliance", "plan_name": "Health Alliance", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp Integrated Solutions LLC", "plan_name": "HealthComp Integrated Solutions LLC", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 1480.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 980.0, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 980.0, "methodology": "fee schedule" }, { "payer_name": "Humana Tricare East", "plan_name": "Humana Tricare East", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Huntsman Mental Health Institute - BHN", "plan_name": "Huntsman Mental Health Institute - BHN", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Imagine 360 Administrators", "plan_name": "Imagine 360 Administrators", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Liberty Healthshare", "plan_name": "Liberty Healthshare", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Devoted Health Plans", "plan_name": "Magellan Devoted Health Plans", "standard_charge_dollar": 1060.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Health Services", "plan_name": "Magellan Health Services", "standard_charge_dollar": 1060.0, "methodology": "fee schedule" }, { "payer_name": "MBA Tricare Supplemental", "plan_name": "MBA Tricare Supplemental", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Medica Elect", "plan_name": "Medica Elect", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 1140.3, "methodology": "fee schedule" }, { "payer_name": "Meritain Health- Aetna Choice POS", "plan_name": "Meritain Health- Aetna Choice POS", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Motivhealth", "plan_name": "Motivhealth", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Mountain Health Co-op", "plan_name": "Mountain Health Co-op", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Priority Health Insurance", "plan_name": "Priority Health Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Provider Network Of America", "plan_name": "Provider Network Of America", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "RMHP Commercial Optun", "plan_name": "RMHP Commercial Optun", "standard_charge_dollar": 1030.0, "methodology": "fee schedule" }, { "payer_name": "RMHP HMO Optum", "plan_name": "RMHP HMO Optum", "standard_charge_dollar": 1030.0, "methodology": "fee schedule" }, { "payer_name": "Routt County Jail & Detention Center", "plan_name": "Routt County Jail & Detention Center", "standard_charge_dollar": 1500.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Insurance", "plan_name": "Select Health Insurance", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Medicare Adv", "plan_name": "Select Health Medicare Adv", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 806.0, "methodology": "fee schedule" }, { "payer_name": "Shelter Point", "plan_name": "Shelter Point", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Simplan Insurance", "plan_name": "Simplan Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "State Of Co Probation", "plan_name": "State Of Co Probation", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Surest - United Health Care", "plan_name": "Surest - United Health Care", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "TLC Benefits Solution Inc.", "plan_name": "TLC Benefits Solution Inc.", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 1480.0, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 1004.0, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care New Mexico", "plan_name": "United Health Care New Mexico", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Student Resources", "plan_name": "United Healthcare Student Resources", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Supplement", "plan_name": "United Healthcare Supplement", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Select Health", "plan_name": "United Select Health", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United World Life", "plan_name": "United World Life", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" } ], "minimum": 803.04, "maximum": 1500.0 } ] }, { "description": "Adol CD Rehab", "code_information": [ { "code": "110009", "type": "RC" }, { "code": "110009", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 1342.0, "methodology": "fee schedule" }, { "payer_name": "Allsavers", "plan_name": "Allsavers", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "AMFirst", "plan_name": "AMFirst", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 1012.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "ASI Tricare Retired Supplement", "plan_name": "ASI Tricare Retired Supplement", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Baylor Scott & White", "plan_name": "Baylor Scott & White", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 803.4, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health Strategies", "plan_name": "Carelon Behavioral Health Strategies", "standard_charge_dollar": 803.4, "methodology": "fee schedule" }, { "payer_name": "Carelon BH APWU", "plan_name": "Carelon BH APWU", "standard_charge_dollar": 803.4, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Employee Asst", "plan_name": "Carelon BH Employee Asst", "standard_charge_dollar": 803.4, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Great West", "plan_name": "Carelon BH Great West", "standard_charge_dollar": 803.4, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 964.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 1034.0, "methodology": "fee schedule" }, { "payer_name": "ComPsych", "plan_name": "ComPsych", "standard_charge_dollar": 1069.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health DHHA", "plan_name": "Denver Health DHHA", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Elevate Silver", "plan_name": "Denver Health Elevate Silver", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Med Plan Cofinity", "plan_name": "Denver Health Med Plan Cofinity", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Employers Health Network", "plan_name": "Employers Health Network", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Enterprise Group Planning, Inc", "plan_name": "Enterprise Group Planning, Inc", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Friday Health Plans", "plan_name": "Friday Health Plans", "standard_charge_dollar": 941.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Gravie Admin Service Aetna", "plan_name": "Gravie Admin Service Aetna", "standard_charge_dollar": 1140.0, "methodology": "fee schedule" }, { "payer_name": "HAP Aetna", "plan_name": "HAP Aetna", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "HCA Optum", "plan_name": "HCA Optum", "standard_charge_dollar": 863.0, "methodology": "fee schedule" }, { "payer_name": "Health Alliance", "plan_name": "Health Alliance", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp Integrated Solutions LLC", "plan_name": "HealthComp Integrated Solutions LLC", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 1480.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 980.0, "methodology": "fee schedule" }, { "payer_name": "Humana Tricare East", "plan_name": "Humana Tricare East", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Huntsman Mental Health Institute - BHN", "plan_name": "Huntsman Mental Health Institute - BHN", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Imagine 360 Administrators", "plan_name": "Imagine 360 Administrators", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Liberty Healthshare", "plan_name": "Liberty Healthshare", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Devoted Health Plans", "plan_name": "Magellan Devoted Health Plans", "standard_charge_dollar": 1060.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Health Services", "plan_name": "Magellan Health Services", "standard_charge_dollar": 1060.0, "methodology": "fee schedule" }, { "payer_name": "MBA Tricare Supplemental", "plan_name": "MBA Tricare Supplemental", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Medica Elect", "plan_name": "Medica Elect", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 1140.3, "methodology": "fee schedule" }, { "payer_name": "Meritain Health- Aetna Choice POS", "plan_name": "Meritain Health- Aetna Choice POS", "standard_charge_dollar": 1174.0, "methodology": "fee schedule" }, { "payer_name": "Motivhealth", "plan_name": "Motivhealth", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Mountain Health Co-op", "plan_name": "Mountain Health Co-op", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Provider Network Of America", "plan_name": "Provider Network Of America", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "RMHP Commercial Optun", "plan_name": "RMHP Commercial Optun", "standard_charge_dollar": 1066.05, "methodology": "fee schedule" }, { "payer_name": "RMHP HMO Optum", "plan_name": "RMHP HMO Optum", "standard_charge_dollar": 1066.05, "methodology": "fee schedule" }, { "payer_name": "Routt County Jail & Detention Center", "plan_name": "Routt County Jail & Detention Center", "standard_charge_dollar": 1500.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Insurance", "plan_name": "Select Health Insurance", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Medicare Adv", "plan_name": "Select Health Medicare Adv", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 806.0, "methodology": "fee schedule" }, { "payer_name": "Shelter Point", "plan_name": "Shelter Point", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Simplan Insurance", "plan_name": "Simplan Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "State Of Co Probation", "plan_name": "State Of Co Probation", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Surest - United Health Care", "plan_name": "Surest - United Health Care", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 1480.0, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 1004.0, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care New Mexico", "plan_name": "United Health Care New Mexico", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Student Resources", "plan_name": "United Healthcare Student Resources", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Supplement", "plan_name": "United Healthcare Supplement", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Select Health", "plan_name": "United Select Health", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United World Life", "plan_name": "United World Life", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" } ], "minimum": 803.4, "maximum": 1500.0 } ] }, { "description": "Restoration bed charge", "code_information": [ { "code": "110010", "type": "RC" }, { "code": "110010", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Simplan Insurance", "plan_name": "Simplan Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "State Restoration", "plan_name": "State Restoration", "standard_charge_dollar": 1050.0, "methodology": "fee schedule" }, { "payer_name": "State Short Term", "plan_name": "State Short Term", "standard_charge_dollar": 1050.0, "methodology": "fee schedule" } ], "minimum": 900.0, "maximum": 1050.0 } ] }, { "description": "Acute Adol Detox", "code_information": [ { "code": "110013", "type": "RC" }, { "code": "110013", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 964.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Health Colorado Medicaid", "plan_name": "Carelon Health Colorado Medicaid", "standard_charge_dollar": 1050.0, "methodology": "fee schedule" }, { "payer_name": "Colo Community Health Alliance", "plan_name": "Colo Community Health Alliance", "standard_charge_dollar": 960.62, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 910.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access CHP+", "plan_name": "Colorado Access CHP+", "standard_charge_dollar": 910.0, "methodology": "fee schedule" }, { "payer_name": "Northeast HP- RMHP", "plan_name": "Northeast HP- RMHP", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Health Plans Medicaid", "plan_name": "Rocky Mountain Health Plans Medicaid", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Simplan Insurance", "plan_name": "Simplan Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" } ], "minimum": 900.0, "maximum": 1100.0 } ] }, { "description": "Acute Gero Detox 3.7", "code_information": [ { "code": "110015", "type": "RC" }, { "code": "110015", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Colo Community Health Alliance", "plan_name": "Colo Community Health Alliance", "standard_charge_dollar": 689.61, "methodology": "fee schedule" }, { "payer_name": "Northeast HP- RMHP", "plan_name": "Northeast HP- RMHP", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Health Plans Medicaid", "plan_name": "Rocky Mountain Health Plans Medicaid", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" } ], "minimum": 689.61, "maximum": 1000.0 } ] }, { "description": "Acute Adol R&B", "code_information": [ { "code": "124", "type": "RC" }, { "code": "110003", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "AARP Health Care Options", "plan_name": "AARP Health Care Options", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "AFLAC Supplemental", "plan_name": "AFLAC Supplemental", "standard_charge_dollar": 936.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Allell-Sunflower State Health Plan", "plan_name": "Allell-Sunflower State Health Plan", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 1342.0, "methodology": "fee schedule" }, { "payer_name": "Allied Benefits Systems", "plan_name": "Allied Benefits Systems", "standard_charge_dollar": 1004.0, "methodology": "fee schedule" }, { "payer_name": "Allied Trades Assistance Program", "plan_name": "Allied Trades Assistance Program", "standard_charge_dollar": 725.0, "methodology": "fee schedule" }, { "payer_name": "Allsavers", "plan_name": "Allsavers", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Ambetter Insurance", "plan_name": "Ambetter Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "American Behavioral", "plan_name": "American Behavioral", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "American Continental Insurance Comapny", "plan_name": "American Continental Insurance Comapny", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "American Republic Corp Ins", "plan_name": "American Republic Corp Ins", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "AMFirst", "plan_name": "AMFirst", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Arizona Medicare", "plan_name": "Anthem BCBS Arizona Medicare", "standard_charge_dollar": 1125.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan Issuer-Medco", "plan_name": "APWU Health Plan Issuer-Medco", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Arapahoe County Dept Of Human Services", "plan_name": "Arapahoe County Dept Of Human Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Arise Health Plan", "plan_name": "Arise Health Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "ASI Tricare Retired Supplement", "plan_name": "ASI Tricare Retired Supplement", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "ASR Health", "plan_name": "ASR Health", "standard_charge_dollar": 972.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Auxiant - PHCS", "plan_name": "Auxiant - PHCS", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Avanta PHCS Verdegard Admin", "plan_name": "Avanta PHCS Verdegard Admin", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Bankers Fidelity", "plan_name": "Bankers Fidelity", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Bankers Life", "plan_name": "Bankers Life", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Baylor Scott & White", "plan_name": "Baylor Scott & White", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "BCBS HMO Colorado", "plan_name": "BCBS HMO Colorado", "standard_charge_dollar": 1092.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Ben-E-Lect", "plan_name": "Ben-E-Lect", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Benefit Management Inc", "plan_name": "Benefit Management Inc", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Bind Benefits, Inc", "plan_name": "Bind Benefits, Inc", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Blue Cross Blue Shield", "plan_name": "Blue Cross Blue Shield", "standard_charge_dollar": 1092.0, "methodology": "fee schedule" }, { "payer_name": "Blue Cross Community Centennial", "plan_name": "Blue Cross Community Centennial", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Brand New Day Insurance", "plan_name": "Brand New Day Insurance", "standard_charge_dollar": 771.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Bright Health Management", "plan_name": "Bright Health Management", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "Bright Health Medicare Advantage", "plan_name": "Bright Health Medicare Advantage", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "Broadspire", "plan_name": "Broadspire", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Care Improvement Plus Of Texas", "plan_name": "Care Improvement Plus Of Texas", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "Care Plus Medicare", "plan_name": "Care Plus Medicare", "standard_charge_dollar": 1023.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 1095.84, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health Strategies", "plan_name": "Carelon Behavioral Health Strategies", "standard_charge_dollar": 1095.84, "methodology": "fee schedule" }, { "payer_name": "Carelon BH APWU", "plan_name": "Carelon BH APWU", "standard_charge_dollar": 1095.84, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Employee Asst", "plan_name": "Carelon BH Employee Asst", "standard_charge_dollar": 1095.84, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Great West", "plan_name": "Carelon BH Great West", "standard_charge_dollar": 1095.84, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 1095.84, "methodology": "fee schedule" }, { "payer_name": "Carelon Health Colorado Medicaid", "plan_name": "Carelon Health Colorado Medicaid", "standard_charge_dollar": 1050.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Medicare Advantage", "plan_name": "Carelon Medicare Advantage", "standard_charge_dollar": 1095.84, "methodology": "fee schedule" }, { "payer_name": "Carelon Northeast Health Partners Mcaid", "plan_name": "Carelon Northeast Health Partners Mcaid", "standard_charge_dollar": 1050.0, "methodology": "fee schedule" }, { "payer_name": "Central States Indemnity", "plan_name": "Central States Indemnity", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "CFI Retirement Plan", "plan_name": "CFI Retirement Plan", "standard_charge_dollar": 936.0, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 1126.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Alliance Health And Life", "plan_name": "Cigna Alliance Health And Life", "standard_charge_dollar": 1126.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 1126.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Health Spring Medicare Advantage", "plan_name": "Cigna Health Spring Medicare Advantage", "standard_charge_dollar": 1126.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 1126.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Supplemental", "plan_name": "Cigna Supplemental", "standard_charge_dollar": 1126.0, "methodology": "fee schedule" }, { "payer_name": "Cigna True Choice Medicare PPO", "plan_name": "Cigna True Choice Medicare PPO", "standard_charge_dollar": 1126.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Zenith Administrators", "plan_name": "Cigna Zenith Administrators", "standard_charge_dollar": 1126.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 1126.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 1126.0, "methodology": "fee schedule" }, { "payer_name": "Clear Springs Health Inc", "plan_name": "Clear Springs Health Inc", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 975.0, "methodology": "fee schedule" }, { "payer_name": "Colo Community Health Alliance", "plan_name": "Colo Community Health Alliance", "standard_charge_dollar": 1145.36, "methodology": "fee schedule" }, { "payer_name": "Colonial Penn Med Supplement", "plan_name": "Colonial Penn Med Supplement", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 1181.16, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 884.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access CHP+", "plan_name": "Colorado Access CHP+", "standard_charge_dollar": 1181.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Health OP", "plan_name": "Colorado Health OP", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Combined Ins Of America", "plan_name": "Combined Ins Of America", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Commonwealth Care Alliance", "plan_name": "Commonwealth Care Alliance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Community Care", "plan_name": "Community Care", "standard_charge_dollar": 771.0, "methodology": "fee schedule" }, { "payer_name": "ComPsych", "plan_name": "ComPsych", "standard_charge_dollar": 925.0, "methodology": "fee schedule" }, { "payer_name": "Continental General Insurace", "plan_name": "Continental General Insurace", "standard_charge_dollar": 1004.0, "methodology": "fee schedule" }, { "payer_name": "Continental Insurance - Marpai Health", "plan_name": "Continental Insurance - Marpai Health", "standard_charge_dollar": 1034.0, "methodology": "fee schedule" }, { "payer_name": "Coordinated Benefit Plan", "plan_name": "Coordinated Benefit Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Costilla County DHS", "plan_name": "Costilla County DHS", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Coventry", "plan_name": "Coventry", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 1339.0, "methodology": "fee schedule" }, { "payer_name": "CSU Funding", "plan_name": "CSU Funding", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Dakatocare", "plan_name": "Dakatocare", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Dean Health Plans", "plan_name": "Dean Health Plans", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health DHHA", "plan_name": "Denver Health DHHA", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Elevate Silver", "plan_name": "Denver Health Elevate Silver", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Med Plan Cofinity", "plan_name": "Denver Health Med Plan Cofinity", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "DHS Weld County Dept Of Human Services", "plan_name": "DHS Weld County Dept Of Human Services", "standard_charge_dollar": 981.2, "methodology": "fee schedule" }, { "payer_name": "Easy Choice Health Plan", "plan_name": "Easy Choice Health Plan", "standard_charge_dollar": 936.0, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 1004.0, "methodology": "fee schedule" }, { "payer_name": "Employer Benefit Service Inc.", "plan_name": "Employer Benefit Service Inc.", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Employers Health Network", "plan_name": "Employers Health Network", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "Enterprise Group Planning, Inc", "plan_name": "Enterprise Group Planning, Inc", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Equitable Life And Casualty Insurance Co", "plan_name": "Equitable Life And Casualty Insurance Co", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Equitable Plan Services", "plan_name": "Equitable Plan Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Evercare - Medicaid New Mexico", "plan_name": "Evercare - Medicaid New Mexico", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Excellus BCBS Medicare Advantage", "plan_name": "Excellus BCBS Medicare Advantage", "standard_charge_dollar": 771.0, "methodology": "fee schedule" }, { "payer_name": "Federal Blue Cross", "plan_name": "Federal Blue Cross", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Fidelis - Medicare Advantage", "plan_name": "Fidelis - Medicare Advantage", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "First Care", "plan_name": "First Care", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "First Choice Health Network", "plan_name": "First Choice Health Network", "standard_charge_dollar": 1004.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 1004.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Freedom Life Ins", "plan_name": "Freedom Life Ins", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Friday Health Plans", "plan_name": "Friday Health Plans", "standard_charge_dollar": 1025.0, "methodology": "fee schedule" }, { "payer_name": "Friday Health Plans CHP+", "plan_name": "Friday Health Plans CHP+", "standard_charge_dollar": 677.67, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Gerber Life Ins Company", "plan_name": "Gerber Life Ins Company", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "GHI", "plan_name": "GHI", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "GHI-BMP", "plan_name": "GHI-BMP", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 867.0, "methodology": "fee schedule" }, { "payer_name": "Gravie Admin Service Aetna", "plan_name": "Gravie Admin Service Aetna", "standard_charge_dollar": 1175.0, "methodology": "fee schedule" }, { "payer_name": "Great Southern Life Ins Co", "plan_name": "Great Southern Life Ins Co", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Guarantee Trust Life Insurance", "plan_name": "Guarantee Trust Life Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "HAP Aetna", "plan_name": "HAP Aetna", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "Harvard Pilgrim HealthCare", "plan_name": "Harvard Pilgrim HealthCare", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "HCA Optum", "plan_name": "HCA Optum", "standard_charge_dollar": 966.0, "methodology": "fee schedule" }, { "payer_name": "Health Alliance", "plan_name": "Health Alliance", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Health Comp Administrators", "plan_name": "Health Comp Administrators", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Health Management Concepts", "plan_name": "Health Management Concepts", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Commercial Claims", "plan_name": "Health Net Commercial Claims", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp Integrated Solutions LLC", "plan_name": "HealthComp Integrated Solutions LLC", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope", "plan_name": "HealthScope", "standard_charge_dollar": 1034.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 1034.0, "methodology": "fee schedule" }, { "payer_name": "Hemet Community Medical Group", "plan_name": "Hemet Community Medical Group", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 1480.0, "methodology": "fee schedule" }, { "payer_name": "Houston Casualty Co", "plan_name": "Houston Casualty Co", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Humana Tricare East", "plan_name": "Humana Tricare East", "standard_charge_dollar": 1156.0, "methodology": "fee schedule" }, { "payer_name": "Huntsman Mental Health Institute - BHN", "plan_name": "Huntsman Mental Health Institute - BHN", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "HWBS Claims", "plan_name": "HWBS Claims", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Illinicare Health Plan", "plan_name": "Illinicare Health Plan", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "ILWU-PMA Coastwise Claims", "plan_name": "ILWU-PMA Coastwise Claims", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Imagine 360 Administrators", "plan_name": "Imagine 360 Administrators", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Insurance Management Inc", "plan_name": "Insurance Management Inc", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Federal Health Benefit Program", "plan_name": "Kaiser Federal Health Benefit Program", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Of Colorado", "plan_name": "Kaiser Of Colorado", "standard_charge_dollar": 1236.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Of Georgia", "plan_name": "Kaiser Of Georgia", "standard_charge_dollar": 1355.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Of Southern CA", "plan_name": "Kaiser Of Southern CA", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Perm CHP", "plan_name": "Kaiser Perm CHP", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente", "plan_name": "Kaiser Permanente", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Denver", "plan_name": "Kaiser Permanente Denver", "standard_charge_dollar": 1382.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Northern", "plan_name": "Kaiser Permanente Northern", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Northwest", "plan_name": "Kaiser Permanente Northwest", "standard_charge_dollar": 900.0, "methodology": 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"payer_name": "Kit Carson County", "plan_name": "Kit Carson County", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Larimer County DHS", "plan_name": "Larimer County DHS", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Liberty Healthshare", "plan_name": "Liberty Healthshare", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Life Shield STM - Ins TPA", "plan_name": "Life Shield STM - Ins TPA", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "LINECO Mental Health & Substance Abuse", "plan_name": "LINECO Mental Health & Substance Abuse", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Lucent Health", "plan_name": "Lucent Health", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "M-Care Medical Network", "plan_name": "M-Care Medical Network", "standard_charge_dollar": 800.0, 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schedule" }, { "payer_name": "NALC Mcare Secondary", "plan_name": "NALC Mcare Secondary", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Nationwide Life", "plan_name": "Nationwide Life", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "NCSRCC Health Fund", "plan_name": "NCSRCC Health Fund", "standard_charge_dollar": 936.0, "methodology": "fee schedule" }, { "payer_name": "Neighborhood Health Plan", "plan_name": "Neighborhood Health Plan", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "Network Health VA", "plan_name": "Network Health VA", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Nevada Mediblue Plus HMO", "plan_name": "Nevada Mediblue Plus HMO", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "New Era Life Insurancce", "plan_name": "New Era Life Insurancce", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Nikola Tesia Alternative High School", "plan_name": "Nikola Tesia Alternative High School", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Northeast HP- RMHP", "plan_name": "Northeast HP- RMHP", "standard_charge_dollar": 1150.0, "methodology": "fee schedule" }, { "payer_name": "Nova Healthcare - Attn Claims", "plan_name": "Nova Healthcare - Attn Claims", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "OHIO Casualty", "plan_name": "OHIO Casualty", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Old Surety Life Ins", "plan_name": "Old Surety Life Ins", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Optima Health Plans", "plan_name": "Optima Health Plans", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "OPTUM EMPIRE HEALTH PLAN", "plan_name": "OPTUM EMPIRE HEALTH PLAN", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Optum Health Behavioral Solutions", "plan_name": "Optum Health Behavioral Solutions", "standard_charge_dollar": 867.0, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Pacific Source Health Plan", "plan_name": "Pacific Source Health Plan", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Pacificare Behavioral Health", "plan_name": "Pacificare Behavioral Health", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "PAI Claims Processing", "plan_name": "PAI Claims Processing", "standard_charge_dollar": 936.0, "methodology": "fee schedule" }, { "payer_name": "ParkCare Plus", "plan_name": "ParkCare Plus", "standard_charge_dollar": 980.0, "methodology": "fee schedule" }, { "payer_name": "Peak Administration", "plan_name": "Peak Administration", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Peak PPA", "plan_name": "Peak PPA", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Penrose Hospital", "plan_name": "Penrose Hospital", "standard_charge_dollar": 875.0, "methodology": "fee schedule" }, { "payer_name": "PHCS - The Health Plan", "plan_name": "PHCS - The Health Plan", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Physicians Mutual Insurance Company", "plan_name": "Physicians Mutual Insurance Company", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Pinnacol Assurance", "plan_name": "Pinnacol Assurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Preferred One Administrative Services", "plan_name": "Preferred One Administrative Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Presbytarian Healthcare", "plan_name": "Presbytarian Healthcare", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Presbyterian Health Plan", "plan_name": "Presbyterian Health Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Priority Health Insurance", "plan_name": "Priority Health Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Private Health Care Systems", "plan_name": "Private Health Care Systems", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Professional Benefit Administrators", "plan_name": "Professional Benefit Administrators", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Progressive Group Of Insurance Comp", "plan_name": "Progressive Group Of Insurance Comp", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Provider Network Of America", "plan_name": "Provider Network Of America", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Psych Care", "plan_name": "Psych Care", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Public Employees Health Program", "plan_name": "Public Employees Health Program", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Pueblo County DHS", "plan_name": "Pueblo County DHS", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Pyramid Life", "plan_name": "Pyramid Life", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Redirect Health - Multiplan", "plan_name": "Redirect Health - Multiplan", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "Regional Care Inc", "plan_name": "Regional Care Inc", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Reserve National", "plan_name": "Reserve National", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Reserve Officers Assoc Insurance", "plan_name": "Reserve Officers Assoc Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Rio Blanco County DHS", "plan_name": "Rio Blanco County DHS", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "RMHP Commercial Optun", "plan_name": "RMHP Commercial Optun", "standard_charge_dollar": 1539.85, "methodology": "fee schedule" }, { "payer_name": "RMHP HMO Optum", "plan_name": "RMHP HMO Optum", "standard_charge_dollar": 1539.85, "methodology": "fee schedule" }, { "payer_name": "RMSCO, Inc", "plan_name": "RMSCO, Inc", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Health Plans Medicaid", "plan_name": "Rocky Mountain Health Plans Medicaid", "standard_charge_dollar": 1150.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Pace", "plan_name": "Rocky Mountain Pace", "standard_charge_dollar": 814.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain-Life Strategies", "plan_name": "Rocky Mountain-Life Strategies", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mtn Pace", "plan_name": "Rocky Mtn Pace", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Safeco Ins Of America", "plan_name": "Safeco Ins Of America", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sanford Health Ins - Multiplan", "plan_name": "Sanford Health Ins - Multiplan", "standard_charge_dollar": 825.0, "methodology": "fee schedule" }, { "payer_name": "Scan Healthcare Of Arizona", "plan_name": "Scan Healthcare Of Arizona", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Scott-White Health Plans", "plan_name": "Scott-White Health Plans", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "SECURE HORIZONS", "plan_name": "SECURE HORIZONS", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons (Medicare)", "plan_name": "Secure Horizons (Medicare)", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons Direct", "plan_name": "Secure Horizons Direct", "standard_charge_dollar": 902.0, "methodology": "fee schedule" }, { "payer_name": "Sedgwick", "plan_name": "Sedgwick", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Select Benefits Administrators", "plan_name": "Select Benefits Administrators", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Insurance", "plan_name": "Select Health Insurance", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Medicare Adv", "plan_name": "Select Health Medicare Adv", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 902.0, "methodology": "fee schedule" }, { "payer_name": "Sentinel Life Insurance", "plan_name": "Sentinel Life Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sentinel Security Life", "plan_name": "Sentinel Security Life", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sentinel Security Life Ins Company", "plan_name": "Sentinel Security Life Ins Company", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sharp Community Med Grp/Secure Horizon", "plan_name": "Sharp Community Med Grp/Secure Horizon", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sheet Metal Workers", "plan_name": "Sheet Metal Workers", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Shelter Point", "plan_name": "Shelter Point", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Simplan Insurance", "plan_name": "Simplan Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Simplified Benefits Administrators", "plan_name": "Simplified Benefits Administrators", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Special Insurance Services", "plan_name": "Special Insurance Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Standard Life And Accident", "plan_name": "Standard Life And Accident", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Standard Life And Accident Insurance", "plan_name": "Standard Life And Accident Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Starmark Insurance", "plan_name": "Starmark Insurance", "standard_charge_dollar": 975.0, "methodology": "fee schedule" }, { "payer_name": "State 12 Short Term", "plan_name": "State 12 Short Term", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "State Farm Insurance", "plan_name": "State Farm Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "State Of Co Probation", "plan_name": "State Of Co Probation", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "State Restoration", "plan_name": "State Restoration", "standard_charge_dollar": 1050.0, "methodology": "fee schedule" }, { "payer_name": "State Short Term", "plan_name": "State Short Term", "standard_charge_dollar": 1050.0, "methodology": "fee schedule" }, { "payer_name": "States General Life", "plan_name": "States General Life", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": 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"methodology": "fee schedule" }, { "payer_name": "Total Longterm Care INC", "plan_name": "Total Longterm Care INC", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "Trans America Ins", "plan_name": "Trans America Ins", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Travelers Insurance", "plan_name": "Travelers Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 988.0, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 988.0, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", 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"standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Vantage Health Plans", "plan_name": "Vantage Health Plans", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Voans Senior Care Community Of Colo", "plan_name": "Voans Senior Care Community Of Colo", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "WEBB TPA", "plan_name": "WEBB TPA", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Wellcare Of Texas", "plan_name": "Wellcare Of Texas", "standard_charge_dollar": 771.0, "methodology": "fee schedule" }, { "payer_name": "Wellfleet", "plan_name": "Wellfleet", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "Winhealth", "plan_name": "Winhealth", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Woodmen Of The World Assured Life Associ", "plan_name": "Woodmen Of The World Assured Life Associ", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Wyoming Pace", "plan_name": "Wyoming Pace", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "ZURICH", "plan_name": "ZURICH", "standard_charge_dollar": 800.0, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "minimum": 600.0, "maximum": 1600.0 } ] }, { "description": "Acute Adult R&B", "code_information": [ { "code": "124", "type": "RC" }, { "code": "110001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "AARP Health Care Options", "plan_name": "AARP Health Care Options", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", 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Health OP", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Combined Ins Of America", "plan_name": "Combined Ins Of America", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Commonwealth Care Alliance", "plan_name": "Commonwealth Care Alliance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Community Care", "plan_name": "Community Care", "standard_charge_dollar": 771.0, "methodology": "fee schedule" }, { "payer_name": "Community Health Options", "plan_name": "Community Health Options", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "ComPsych", "plan_name": "ComPsych", "standard_charge_dollar": 1069.0, "methodology": "fee schedule" }, { "payer_name": "Continental General Insurace", "plan_name": "Continental General Insurace", "standard_charge_dollar": 1004.0, "methodology": "fee schedule" }, { "payer_name": "Continental Insurance - Marpai Health", "plan_name": "Continental Insurance - Marpai Health", "standard_charge_dollar": 1034.0, "methodology": "fee schedule" }, { "payer_name": "Coordinated Benefit Plan", "plan_name": "Coordinated Benefit Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Costilla County DHS", "plan_name": "Costilla County DHS", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Coventry", "plan_name": "Coventry", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 1339.0, "methodology": "fee schedule" }, { "payer_name": "CSU Funding", "plan_name": "CSU Funding", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": 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"methodology": "fee schedule" }, { "payer_name": "DHS Weld County Dept Of Human Services", "plan_name": "DHS Weld County Dept Of Human Services", "standard_charge_dollar": 981.2, "methodology": "fee schedule" }, { "payer_name": "Easy Choice Health Plan", "plan_name": "Easy Choice Health Plan", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 1004.0, "methodology": "fee schedule" }, { "payer_name": "Employer Benefit Service Inc.", "plan_name": "Employer Benefit Service Inc.", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Employers Health Network", "plan_name": "Employers Health Network", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "Enterprise Group Planning, Inc", "plan_name": "Enterprise Group Planning, Inc", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Equitable Life And Casualty Insurance Co", "plan_name": "Equitable Life And Casualty Insurance Co", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Equitable Plan Services", "plan_name": "Equitable Plan Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Evercare - Medicaid New Mexico", "plan_name": "Evercare - Medicaid New Mexico", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Excellus BCBS Medicare Advantage", "plan_name": "Excellus BCBS Medicare Advantage", "standard_charge_dollar": 771.0, "methodology": "fee schedule" }, { "payer_name": "FCBS", "plan_name": "FCBS", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "Federal Blue Cross", "plan_name": "Federal Blue Cross", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Fidelis - Medicare Advantage", "plan_name": "Fidelis - Medicare Advantage", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "First Care", "plan_name": "First Care", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "First Choice Health Network", "plan_name": "First Choice Health Network", "standard_charge_dollar": 1004.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Freedom Life Ins", "plan_name": "Freedom Life Ins", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Friday Health Plans", "plan_name": "Friday Health Plans", "standard_charge_dollar": 1025.0, "methodology": "fee schedule" }, { "payer_name": "Friday Health Plans CHP+", "plan_name": "Friday Health Plans CHP+", "standard_charge_dollar": 677.67, "methodology": "fee schedule" }, { "payer_name": "Fringe Benefit Group", "plan_name": "Fringe Benefit Group", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Gerber Life Ins Company", "plan_name": "Gerber Life Ins Company", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "GHI", "plan_name": "GHI", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "GHI-BMP", "plan_name": "GHI-BMP", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 867.0, "methodology": "fee schedule" }, { "payer_name": "Gravie Admin Service Aetna", "plan_name": "Gravie Admin Service Aetna", "standard_charge_dollar": 1175.0, "methodology": "fee schedule" }, { "payer_name": "Great Southern Life Ins Co", "plan_name": "Great Southern Life Ins Co", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Guarantee Trust Life Insurance", "plan_name": "Guarantee Trust Life Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "HAP Aetna", "plan_name": "HAP Aetna", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "Harvard Pilgrim HealthCare", "plan_name": "Harvard Pilgrim HealthCare", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "HCA Optum", "plan_name": "HCA Optum", "standard_charge_dollar": 966.0, "methodology": "fee schedule" }, { "payer_name": "Health Alliance", "plan_name": "Health Alliance", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Health Comp Administrators", "plan_name": "Health Comp Administrators", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Health EZ", "plan_name": "Health EZ", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Health Management Concepts", "plan_name": "Health Management Concepts", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Commercial Claims", "plan_name": "Health Net Commercial Claims", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp Integrated Solutions LLC", "plan_name": "HealthComp Integrated Solutions LLC", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope", "plan_name": "HealthScope", "standard_charge_dollar": 1034.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 1034.0, "methodology": "fee schedule" }, { "payer_name": "Hemet Community Medical Group", "plan_name": "Hemet Community Medical Group", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 1480.0, "methodology": "fee schedule" }, { "payer_name": "Houston Casualty Co", "plan_name": "Houston Casualty Co", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Humana Tricare East", "plan_name": "Humana Tricare East", "standard_charge_dollar": 1156.0, "methodology": "fee schedule" }, { "payer_name": "Huntsman Mental Health Institute - BHN", "plan_name": "Huntsman Mental Health Institute - BHN", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "HWBS Claims", "plan_name": "HWBS Claims", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Illinicare Health Plan", "plan_name": "Illinicare Health Plan", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "ILWU-PMA Coastwise Claims", "plan_name": "ILWU-PMA Coastwise Claims", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Imagine 360 Administrators", "plan_name": "Imagine 360 Administrators", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "InnovAge Pace", "plan_name": "InnovAge Pace", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Insurance Management Inc", "plan_name": "Insurance Management Inc", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Federal Health Benefit Program", "plan_name": "Kaiser Federal Health Benefit Program", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Of Colorado", "plan_name": "Kaiser Of Colorado", "standard_charge_dollar": 1236.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Of Georgia", "plan_name": "Kaiser Of Georgia", "standard_charge_dollar": 1355.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Of Southern CA", "plan_name": "Kaiser Of Southern CA", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Perm CHP", "plan_name": "Kaiser Perm CHP", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente", "plan_name": "Kaiser Permanente", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Denver", "plan_name": "Kaiser Permanente Denver", "standard_charge_dollar": 1382.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Northern", "plan_name": "Kaiser Permanente Northern", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Northwest", "plan_name": "Kaiser Permanente Northwest", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Senior Advantage HMO", "plan_name": "Kaiser Permanente Senior Advantage HMO", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente/KPIC", "plan_name": "Kaiser Permanente/KPIC", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanete Of Harrington", "plan_name": "Kaiser Permanete Of Harrington", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Southern California", "plan_name": "Kaiser Southern California", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Kayenta Alternative Rural Hospital", "plan_name": "Kayenta Alternative Rural Hospital", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Kemper Insurance Benefits", "plan_name": "Kemper Insurance Benefits", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Kit Carson County", "plan_name": "Kit Carson County", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "LA Health Care Plan", "plan_name": "LA Health Care Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Larimer County DHS", "plan_name": "Larimer County DHS", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Liberty Healthshare", "plan_name": "Liberty Healthshare", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Life Shield STM - Ins TPA", "plan_name": "Life Shield STM - Ins TPA", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "LINECO Mental Health & Substance Abuse", "plan_name": "LINECO Mental Health & Substance Abuse", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Lucent Health", "plan_name": "Lucent Health", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "M-Care Medical Network", "plan_name": "M-Care Medical Network", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 1004.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Devoted Health Plans", "plan_name": "Magellan Devoted Health Plans", "standard_charge_dollar": 1060.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Health Services", "plan_name": "Magellan Health Services", "standard_charge_dollar": 1060.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Insurance", "plan_name": "Magellan Insurance", "standard_charge_dollar": 1060.0, "methodology": "fee schedule" }, { "payer_name": "Mailhandlers", "plan_name": "Mailhandlers", "standard_charge_dollar": 867.0, "methodology": "fee schedule" }, { "payer_name": "Managed Care Insurance - MBR Claims", "plan_name": "Managed Care Insurance - MBR Claims", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Network Group", "plan_name": "Managed Health Network Group", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Manhatten Life Supplemental", "plan_name": "Manhatten Life Supplemental", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Medcost Ultra", "plan_name": "Medcost Ultra", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Medica Elect", "plan_name": "Medica Elect", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Medical Mutual Ins", "plan_name": "Medical Mutual Ins", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Medico Insurance Supplement", "plan_name": "Medico Insurance Supplement", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 1140.3, "methodology": "fee schedule" }, { "payer_name": "Meritain Health- Aetna Choice POS", "plan_name": "Meritain Health- Aetna Choice POS", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "MERP Administrative Services", "plan_name": "MERP Administrative Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "MHNET", "plan_name": "MHNET", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "Mines And Associates, PC", "plan_name": "Mines And Associates, PC", "standard_charge_dollar": 1600.0, "methodology": "fee schedule" }, { "payer_name": "Mitchell International", "plan_name": "Mitchell International", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "MOAA Mediplus", "plan_name": "MOAA Mediplus", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Modern Assistance Program", "plan_name": "Modern Assistance Program", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Moffat County DHS", "plan_name": "Moffat County DHS", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Of California", "plan_name": "Molina Healthcare Of California", "standard_charge_dollar": 771.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Of New Mexico", "plan_name": "Molina Healthcare Of New Mexico", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Of Texas", "plan_name": "Molina Healthcare Of Texas", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Of Washington", "plan_name": "Molina Healthcare Of Washington", "standard_charge_dollar": 771.0, "methodology": "fee schedule" }, { "payer_name": "Motivhealth", "plan_name": "Motivhealth", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Mountain Health Co-op", "plan_name": "Mountain Health Co-op", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "Multiplan", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "Mutual Of Omaha", "plan_name": "Mutual Of Omaha", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "MVP Healthcare Value Opts", "plan_name": "MVP Healthcare Value Opts", "standard_charge_dollar": 993.0, "methodology": "fee schedule" }, { "payer_name": "NALC Health Benefit Plan", "plan_name": "NALC Health Benefit Plan", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "NALC Mcare Secondary", "plan_name": "NALC Mcare Secondary", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Nationwide Life", "plan_name": "Nationwide Life", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "NCSRCC Health Fund", "plan_name": "NCSRCC Health Fund", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "Neighborhood Health Plan", "plan_name": "Neighborhood Health Plan", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "Network Health VA", "plan_name": "Network Health VA", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Nevada Mediblue Plus HMO", "plan_name": "Nevada Mediblue Plus HMO", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "New Era Life Insurancce", "plan_name": "New Era Life Insurancce", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "New Mexico Medicaid", "plan_name": "New Mexico Medicaid", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Nikola Tesia Alternative High School", "plan_name": "Nikola Tesia Alternative High School", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Northeast HP- RMHP", "plan_name": "Northeast HP- RMHP", "standard_charge_dollar": 1150.0, "methodology": "fee schedule" }, { "payer_name": "Nova Healthcare - Attn Claims", "plan_name": "Nova Healthcare - Attn Claims", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "OHIO Casualty", "plan_name": "OHIO Casualty", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Old Surety Life Ins", "plan_name": "Old Surety Life Ins", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Optima Health Plans", "plan_name": "Optima Health Plans", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "OPTUM EMPIRE HEALTH PLAN", "plan_name": "OPTUM EMPIRE HEALTH PLAN", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Optum Health Behavioral Solutions", "plan_name": "Optum Health Behavioral Solutions", "standard_charge_dollar": 867.0, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Pacific Source Health Plan", "plan_name": "Pacific Source Health Plan", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Pacificare Behavioral Health", "plan_name": "Pacificare Behavioral Health", "standard_charge_dollar": 902.0, "methodology": "fee schedule" }, { "payer_name": "PAI Claims Processing", "plan_name": "PAI Claims Processing", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "ParkCare Plus", "plan_name": "ParkCare Plus", "standard_charge_dollar": 980.0, "methodology": "fee schedule" }, { "payer_name": "Peak Administration", "plan_name": "Peak Administration", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Peak PPA", "plan_name": "Peak PPA", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Penrose Hospital", "plan_name": "Penrose Hospital", "standard_charge_dollar": 875.0, "methodology": "fee schedule" }, { "payer_name": "PHCS - The Health Plan", "plan_name": "PHCS - The Health Plan", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Physicians Mutual Insurance Company", "plan_name": "Physicians Mutual Insurance Company", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Pinnacol Assurance", "plan_name": "Pinnacol Assurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Preferred One Administrative Services", "plan_name": "Preferred One Administrative Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Presbyterian Health Plan", "plan_name": "Presbyterian Health Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Priority Health Insurance", "plan_name": "Priority Health Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Private Health Care Systems", "plan_name": "Private Health Care Systems", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Professional Benefit Administrators", "plan_name": "Professional Benefit Administrators", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Progressive Group Of Insurance Comp", "plan_name": "Progressive Group Of Insurance Comp", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Provider Network Of America", "plan_name": "Provider Network Of America", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Psych Care", "plan_name": "Psych Care", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Public Employees Health Program", "plan_name": "Public Employees Health Program", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Pueblo County DHS", "plan_name": "Pueblo County DHS", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Pyramid Life", "plan_name": "Pyramid Life", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Redirect Health - Multiplan", "plan_name": "Redirect Health - Multiplan", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "Regional Care Inc", "plan_name": "Regional Care Inc", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Reserve National", "plan_name": "Reserve National", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Reserve Officers Assoc Insurance", "plan_name": "Reserve Officers Assoc Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Rio Blanco County DHS", "plan_name": "Rio Blanco County DHS", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "RMHP Commercial Optun", "plan_name": "RMHP Commercial Optun", "standard_charge_dollar": 1539.85, "methodology": "fee schedule" }, { "payer_name": "RMHP HMO Optum", "plan_name": "RMHP HMO Optum", "standard_charge_dollar": 1539.85, "methodology": "fee schedule" }, { "payer_name": "RMHP Medicare Optum", "plan_name": "RMHP Medicare Optum", "standard_charge_dollar": 813.0, "methodology": "fee schedule" }, { "payer_name": "RMSCO, Inc", "plan_name": "RMSCO, Inc", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Health Plans Medicaid", "plan_name": "Rocky Mountain Health Plans Medicaid", "standard_charge_dollar": 1150.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Pace", "plan_name": "Rocky Mountain Pace", "standard_charge_dollar": 814.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain-Life Strategies", "plan_name": "Rocky Mountain-Life Strategies", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mtn Pace", "plan_name": "Rocky Mtn Pace", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Routt County Jail & Detention Center", "plan_name": "Routt County Jail & Detention Center", "standard_charge_dollar": 1500.0, "methodology": "fee schedule" }, { "payer_name": "Safeco Ins Of America", "plan_name": "Safeco Ins Of America", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sanford Health Ins - Multiplan", "plan_name": "Sanford Health Ins - Multiplan", "standard_charge_dollar": 825.0, "methodology": "fee schedule" }, { "payer_name": "Scan Healthcare Of Arizona", "plan_name": "Scan Healthcare Of Arizona", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Scott-White Health Plans", "plan_name": "Scott-White Health Plans", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "SECURE HORIZONS", "plan_name": "SECURE HORIZONS", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons (Medicare)", "plan_name": "Secure Horizons (Medicare)", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons Direct", "plan_name": "Secure Horizons Direct", "standard_charge_dollar": 867.0, "methodology": "fee schedule" }, { "payer_name": "Sedgwick", "plan_name": "Sedgwick", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Select Benefits Administrators", "plan_name": "Select Benefits Administrators", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Insurance", "plan_name": "Select Health Insurance", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Medicare Adv", "plan_name": "Select Health Medicare Adv", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 902.0, "methodology": "fee schedule" }, { "payer_name": "Sentinel Life Insurance", "plan_name": "Sentinel Life Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sentinel Security Life", "plan_name": "Sentinel Security Life", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sentinel Security Life Ins Company", "plan_name": "Sentinel Security Life Ins Company", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sharp Community Med Grp/Secure Horizon", "plan_name": "Sharp Community Med Grp/Secure Horizon", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sheet Metal Workers", "plan_name": "Sheet Metal Workers", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Shelter Point", "plan_name": "Shelter Point", "standard_charge_dollar": 1000.0, "methodology": 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"plan_name": "Starmark Insurance", "standard_charge_dollar": 975.0, "methodology": "fee schedule" }, { "payer_name": "State 12 Short Term", "plan_name": "State 12 Short Term", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "State Farm Insurance", "plan_name": "State Farm Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "State Of Co Probation", "plan_name": "State Of Co Probation", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "State Restoration", "plan_name": "State Restoration", "standard_charge_dollar": 1050.0, "methodology": "fee schedule" }, { "payer_name": "State Short Term", "plan_name": "State Short Term", "standard_charge_dollar": 1050.0, "methodology": "fee schedule" }, { "payer_name": "States General Life", "plan_name": "States General Life", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Surest - United Health Care", "plan_name": "Surest - United Health Care", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Teller County DHS", "plan_name": "Teller County DHS", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "The GEMGroup", "plan_name": "The GEMGroup", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Thrivent Financial For Lutherns", "plan_name": "Thrivent Financial For Lutherns", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "TLC Benefits Solution Inc.", "plan_name": "TLC Benefits Solution Inc.", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Total Long Term Care", "plan_name": "Total Long Term Care", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "Total Longterm Care INC", "plan_name": "Total Longterm Care INC", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "Trans America Ins", "plan_name": "Trans America Ins", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Travelers Insurance", "plan_name": "Travelers Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 1226.0, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 988.0, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 1069.7, "methodology": "fee 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"payer_name": "UHC Community Plan/AZ Phys IPA", "plan_name": "UHC Community Plan/AZ Phys IPA", "standard_charge_dollar": 902.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 966.0, "methodology": "fee schedule" }, { "payer_name": "UMR/CEBT-PM085516", "plan_name": "UMR/CEBT-PM085516", "standard_charge_dollar": 867.0, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Unicare State Indeminity Plan", "plan_name": "Unicare State Indeminity Plan", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Unified Life Insurance Company", "plan_name": "Unified Life Insurance Company", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care New Mexico", "plan_name": "United Health Care New Mexico", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Student Resources", "plan_name": "United Healthcare Student Resources", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Supplement", "plan_name": "United Healthcare Supplement", "standard_charge_dollar": 1065.0, "methodology": "fee 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"payer_name": "Voans Senior Care Community Of Colo", "plan_name": "Voans Senior Care Community Of Colo", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Volunteers Of America Natl Assoc", "plan_name": "Volunteers Of America Natl Assoc", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "WEBB TPA", "plan_name": "WEBB TPA", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Wellcare Of Texas", "plan_name": "Wellcare Of Texas", "standard_charge_dollar": 771.0, "methodology": "fee schedule" }, { "payer_name": "Wellfleet", "plan_name": "Wellfleet", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "Winhealth", "plan_name": "Winhealth", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Woodmen Of The World Assured Life Associ", "plan_name": "Woodmen Of The World Assured Life Associ", "standard_charge_dollar": 800.0, "methodology": 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"methodology": "fee schedule" }, { "payer_name": "Denver Health DHHA", "plan_name": "Denver Health DHHA", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Elevate Silver", "plan_name": "Denver Health Elevate Silver", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Med Plan Cofinity", "plan_name": "Denver Health Med Plan Cofinity", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "DHS Weld County Dept Of Human Services", "plan_name": "DHS Weld County Dept Of Human Services", "standard_charge_dollar": 981.2, "methodology": "fee schedule" }, { "payer_name": "Easy Choice Health Plan", "plan_name": "Easy Choice Health Plan", "standard_charge_dollar": 936.0, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 1004.0, "methodology": "fee schedule" }, { "payer_name": "Employer Benefit Service Inc.", "plan_name": "Employer Benefit Service Inc.", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Employers Health Network", "plan_name": "Employers Health Network", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "Enterprise Group Planning, Inc", "plan_name": "Enterprise Group Planning, Inc", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Equitable Life And Casualty Insurance Co", "plan_name": "Equitable Life And Casualty Insurance Co", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Equitable Plan Services", "plan_name": "Equitable Plan Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Evercare - Medicaid New Mexico", "plan_name": "Evercare - Medicaid New Mexico", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Excellus BCBS Medicare Advantage", "plan_name": "Excellus BCBS Medicare Advantage", "standard_charge_dollar": 771.0, "methodology": "fee schedule" }, { "payer_name": "FCBS", "plan_name": "FCBS", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "Federal Blue Cross", "plan_name": "Federal Blue Cross", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Fidelis - Medicare Advantage", "plan_name": "Fidelis - Medicare Advantage", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "First Care", "plan_name": "First Care", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "First Choice Health Network", "plan_name": 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"standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Gerber Life Ins Company", "plan_name": "Gerber Life Ins Company", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "GHI", "plan_name": "GHI", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "GHI-BMP", "plan_name": "GHI-BMP", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 867.0, "methodology": "fee schedule" }, { "payer_name": "Gravie Admin Service Aetna", "plan_name": "Gravie Admin Service Aetna", "standard_charge_dollar": 1175.0, "methodology": "fee schedule" }, { "payer_name": "Great Southern Life Ins Co", "plan_name": "Great Southern Life Ins Co", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Guarantee Trust Life Insurance", "plan_name": "Guarantee Trust Life Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "HAP Aetna", "plan_name": "HAP Aetna", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "Harvard Pilgrim HealthCare", "plan_name": "Harvard Pilgrim HealthCare", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "HCA Optum", "plan_name": "HCA Optum", "standard_charge_dollar": 966.0, "methodology": "fee schedule" }, { "payer_name": "Health Alliance", "plan_name": "Health Alliance", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Health Comp Administrators", "plan_name": "Health Comp Administrators", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Health EZ", "plan_name": "Health EZ", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Health Management Concepts", "plan_name": "Health Management Concepts", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Commercial Claims", "plan_name": "Health Net Commercial Claims", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp Integrated Solutions LLC", "plan_name": "HealthComp Integrated Solutions LLC", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope", "plan_name": "HealthScope", "standard_charge_dollar": 1034.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope 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"HWBS Claims", "plan_name": "HWBS Claims", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Illinicare Health Plan", "plan_name": "Illinicare Health Plan", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "ILWU-PMA Coastwise Claims", "plan_name": "ILWU-PMA Coastwise Claims", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Imagine 360 Administrators", "plan_name": "Imagine 360 Administrators", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Insurance Management Inc", "plan_name": "Insurance Management Inc", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Federal Health Benefit Program", "plan_name": "Kaiser Federal Health Benefit Program", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Of Colorado", "plan_name": "Kaiser Of Colorado", "standard_charge_dollar": 1236.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Of Georgia", "plan_name": "Kaiser Of Georgia", "standard_charge_dollar": 1355.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Of Southern CA", "plan_name": "Kaiser Of Southern CA", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Perm CHP", "plan_name": "Kaiser Perm CHP", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente", "plan_name": "Kaiser Permanente", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Denver", "plan_name": "Kaiser Permanente Denver", "standard_charge_dollar": 1382.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Northern", "plan_name": "Kaiser Permanente Northern", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Northwest", "plan_name": "Kaiser Permanente Northwest", 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900.0, "methodology": "fee schedule" }, { "payer_name": "Kit Carson County", "plan_name": "Kit Carson County", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "LA Health Care Plan", "plan_name": "LA Health Care Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Larimer County DHS", "plan_name": "Larimer County DHS", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Liberty Healthshare", "plan_name": "Liberty Healthshare", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Life Shield STM - Ins TPA", "plan_name": "Life Shield STM - Ins TPA", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "LINECO Mental Health & Substance Abuse", "plan_name": "LINECO Mental Health & Substance Abuse", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Lucent Health", "plan_name": "Lucent Health", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "M-Care Medical Network", "plan_name": "M-Care Medical Network", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 1004.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Devoted Health Plans", "plan_name": "Magellan Devoted Health Plans", "standard_charge_dollar": 1060.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Health Services", "plan_name": "Magellan Health Services", "standard_charge_dollar": 1060.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Insurance", "plan_name": "Magellan Insurance", "standard_charge_dollar": 1060.0, "methodology": "fee schedule" }, { "payer_name": "Mailhandlers", "plan_name": "Mailhandlers", "standard_charge_dollar": 867.0, "methodology": "fee schedule" }, { "payer_name": "Managed Care Insurance - MBR Claims", "plan_name": "Managed Care Insurance - MBR Claims", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Network Group", "plan_name": "Managed Health Network Group", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Manhatten Life Supplemental", "plan_name": "Manhatten Life Supplemental", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Mayo Health Solutions", "plan_name": "Mayo Health Solutions", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Medcost Ultra", "plan_name": "Medcost Ultra", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Medica Elect", "plan_name": "Medica Elect", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Medical Mutual Ins", "plan_name": "Medical Mutual Ins", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Medico Insurance Supplement", "plan_name": "Medico Insurance Supplement", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 1140.3, "methodology": "fee schedule" }, { "payer_name": "Meritain Health- Aetna Choice POS", "plan_name": "Meritain Health- Aetna Choice POS", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "MERP Administrative Services", "plan_name": "MERP Administrative Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "MHNET", "plan_name": "MHNET", "standard_charge_dollar": 936.0, "methodology": "fee schedule" }, { "payer_name": "Mines And Associates, PC", "plan_name": "Mines And Associates, PC", "standard_charge_dollar": 1082.0, "methodology": "fee schedule" }, { "payer_name": "Mitchell International", "plan_name": "Mitchell International", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "MOAA Mediplus", "plan_name": "MOAA Mediplus", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Modern Assistance Program", "plan_name": "Modern Assistance Program", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Moffat County DHS", "plan_name": "Moffat County DHS", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Of California", "plan_name": "Molina Healthcare Of California", "standard_charge_dollar": 771.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Of New Mexico", "plan_name": "Molina Healthcare Of New Mexico", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Of Texas", "plan_name": "Molina Healthcare Of Texas", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Of Washington", "plan_name": "Molina Healthcare Of Washington", "standard_charge_dollar": 771.0, "methodology": "fee schedule" }, { "payer_name": "Motivhealth", "plan_name": "Motivhealth", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Mountain Health Co-op", "plan_name": "Mountain Health Co-op", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "Multiplan", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "Mutual Of Omaha", "plan_name": "Mutual Of Omaha", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "MVP Healthcare Value Opts", "plan_name": "MVP Healthcare Value Opts", "standard_charge_dollar": 993.0, "methodology": "fee schedule" }, { "payer_name": "NALC Health Benefit Plan", "plan_name": "NALC Health Benefit Plan", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "NALC Mcare Secondary", "plan_name": "NALC Mcare Secondary", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Nationwide Life", "plan_name": "Nationwide Life", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "NCSRCC Health Fund", "plan_name": "NCSRCC Health Fund", "standard_charge_dollar": 936.0, "methodology": "fee schedule" }, { "payer_name": "Neighborhood Health Plan", "plan_name": "Neighborhood Health Plan", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "Network Health VA", "plan_name": "Network Health VA", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Nevada Mediblue Plus HMO", "plan_name": "Nevada Mediblue Plus HMO", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "New Era Life Insurancce", "plan_name": "New Era Life Insurancce", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Nikola Tesia Alternative High School", "plan_name": "Nikola Tesia Alternative High School", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Northeast HP- RMHP", "plan_name": "Northeast HP- RMHP", "standard_charge_dollar": 1150.0, "methodology": "fee schedule" }, { "payer_name": "Nova Healthcare - Attn Claims", "plan_name": "Nova Healthcare - Attn Claims", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "OHIO Casualty", "plan_name": "OHIO Casualty", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Old Surety Life Ins", "plan_name": "Old Surety Life Ins", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Optima Health Plans", "plan_name": "Optima Health Plans", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "OPTUM EMPIRE HEALTH PLAN", "plan_name": "OPTUM EMPIRE HEALTH PLAN", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Optum Health Behavioral Solutions", "plan_name": "Optum Health Behavioral Solutions", "standard_charge_dollar": 867.0, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Pacific Source Health Plan", "plan_name": "Pacific Source Health Plan", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Pacificare Behavioral Health", "plan_name": "Pacificare Behavioral Health", "standard_charge_dollar": 867.0, "methodology": "fee schedule" }, { "payer_name": "PAI Claims Processing", "plan_name": "PAI Claims Processing", "standard_charge_dollar": 936.0, "methodology": "fee schedule" }, { "payer_name": "ParkCare Plus", "plan_name": "ParkCare Plus", "standard_charge_dollar": 980.0, "methodology": "fee schedule" }, { "payer_name": "Peak Administration", "plan_name": "Peak Administration", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Peak PPA", "plan_name": "Peak PPA", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Penrose Hospital", "plan_name": "Penrose Hospital", "standard_charge_dollar": 875.0, "methodology": "fee schedule" }, { "payer_name": "PHCS - The Health Plan", "plan_name": "PHCS - The Health Plan", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Physicians Mutual Insurance Company", "plan_name": "Physicians Mutual Insurance Company", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Pinnacol Assurance", "plan_name": "Pinnacol Assurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Preferred One Administrative Services", "plan_name": "Preferred One Administrative Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Presbyterian Health Plan", "plan_name": "Presbyterian Health Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Priority Health Insurance", "plan_name": "Priority Health Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Private Health Care Systems", "plan_name": "Private Health Care Systems", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Professional Benefit Administrators", "plan_name": "Professional Benefit Administrators", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Progressive Group Of Insurance Comp", "plan_name": "Progressive Group Of Insurance Comp", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Provider Network Of America", "plan_name": "Provider Network Of America", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Psych Care", "plan_name": "Psych Care", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Public Employees Health Program", "plan_name": "Public Employees Health Program", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Pyramid Life", "plan_name": "Pyramid Life", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Redirect Health - Multiplan", "plan_name": "Redirect Health - Multiplan", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "Regional Care Inc", "plan_name": "Regional Care Inc", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Reserve National", "plan_name": "Reserve National", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Reserve Officers Assoc Insurance", "plan_name": "Reserve Officers Assoc Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Rio Blanco County DHS", "plan_name": "Rio Blanco County DHS", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "RMHP Commercial Optun", "plan_name": "RMHP Commercial Optun", "standard_charge_dollar": 1539.85, "methodology": "fee schedule" }, { "payer_name": "RMHP HMO Optum", "plan_name": "RMHP HMO Optum", "standard_charge_dollar": 1539.85, "methodology": "fee schedule" }, { "payer_name": "RMSCO, Inc", "plan_name": "RMSCO, Inc", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Health Plans Medicaid", "plan_name": "Rocky Mountain Health Plans Medicaid", "standard_charge_dollar": 1150.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain-Life Strategies", "plan_name": "Rocky Mountain-Life Strategies", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mtn Pace", "plan_name": "Rocky Mtn Pace", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Routt County Jail & Detention Center", "plan_name": "Routt County Jail & Detention Center", "standard_charge_dollar": 1500.0, "methodology": "fee schedule" }, { "payer_name": "Safeco Ins Of America", "plan_name": "Safeco Ins Of America", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sanford Health Ins - Multiplan", "plan_name": "Sanford Health Ins - Multiplan", "standard_charge_dollar": 825.0, "methodology": "fee schedule" }, { "payer_name": "Scan Healthcare Of Arizona", "plan_name": "Scan Healthcare Of Arizona", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Scott-White Health Plans", "plan_name": "Scott-White Health Plans", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "SECURE HORIZONS", "plan_name": "SECURE HORIZONS", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons (Medicare)", "plan_name": "Secure Horizons (Medicare)", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons Direct", "plan_name": "Secure Horizons Direct", "standard_charge_dollar": 902.0, "methodology": "fee schedule" }, { "payer_name": "Sedgwick", "plan_name": "Sedgwick", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Select Benefits Administrators", "plan_name": "Select Benefits Administrators", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Insurance", "plan_name": "Select Health Insurance", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Medicare Adv", "plan_name": "Select Health Medicare Adv", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 902.0, "methodology": "fee schedule" }, { "payer_name": "Sentinel Life Insurance", "plan_name": "Sentinel Life Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sentinel Security Life", "plan_name": "Sentinel Security Life", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sentinel Security Life Ins Company", "plan_name": "Sentinel Security Life Ins Company", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sharp Community Med Grp/Secure Horizon", "plan_name": "Sharp Community Med Grp/Secure Horizon", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sheet Metal Workers", "plan_name": "Sheet Metal Workers", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Shelter Point", "plan_name": "Shelter Point", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Sierra Health & Life", "plan_name": "Sierra Health & Life", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Simplan Insurance", "plan_name": "Simplan Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Simplified Benefits Administrators", "plan_name": "Simplified Benefits Administrators", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Special Insurance Services", "plan_name": "Special Insurance Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Standard Life And Accident", "plan_name": "Standard Life And Accident", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Standard Life And Accident Insurance", "plan_name": "Standard Life And Accident Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Starmark Insurance", "plan_name": "Starmark Insurance", "standard_charge_dollar": 975.0, "methodology": "fee schedule" }, { "payer_name": "State 12 Short Term", "plan_name": "State 12 Short Term", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "State Farm Insurance", "plan_name": "State Farm Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "State Of Co Probation", "plan_name": "State Of Co Probation", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "State Restoration", "plan_name": "State Restoration", "standard_charge_dollar": 1050.0, "methodology": "fee schedule" }, { "payer_name": "State Short Term", "plan_name": "State Short Term", "standard_charge_dollar": 1050.0, "methodology": "fee schedule" }, { "payer_name": "States General Life", "plan_name": "States General Life", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Surest - United Health Care", "plan_name": "Surest - United Health Care", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Teller County DHS", "plan_name": "Teller County DHS", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "The GEMGroup", "plan_name": "The GEMGroup", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Thrivent Financial For Lutherns", "plan_name": "Thrivent Financial For Lutherns", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Thrivent Medicare Supplement", "plan_name": "Thrivent Medicare Supplement", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "TLC Benefits Solution Inc.", "plan_name": "TLC Benefits Solution Inc.", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Total Long Term Care", "plan_name": "Total Long Term Care", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "Total Longterm Care INC", "plan_name": "Total Longterm Care INC", "standard_charge_dollar": 755.0, "methodology": "fee schedule" }, { "payer_name": "Trans America Ins", "plan_name": "Trans America Ins", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Travelers Insurance", "plan_name": "Travelers Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 1226.0, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 988.0, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 1016.5, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 1016.5, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 1016.5, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 1069.7, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 1480.0, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 1004.0, "methodology": "fee schedule" }, { "payer_name": "Tufts Health Plan", "plan_name": "Tufts Health Plan", "standard_charge_dollar": 1072.0, "methodology": "fee schedule" }, { "payer_name": "UCare", "plan_name": "UCare", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "UHC COMMUNITY PLAN", "plan_name": "UHC COMMUNITY PLAN", "standard_charge_dollar": 867.0, "methodology": "fee schedule" }, { "payer_name": "UHC Community Plan/AZ Phys IPA", "plan_name": "UHC Community Plan/AZ Phys IPA", "standard_charge_dollar": 902.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 966.0, "methodology": "fee schedule" }, { "payer_name": "UMR/CEBT-PM085516", "plan_name": "UMR/CEBT-PM085516", "standard_charge_dollar": 867.0, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Unicare State Indeminity Plan", "plan_name": "Unicare State Indeminity Plan", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Unified Life Insurance Company", "plan_name": "Unified Life Insurance Company", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care New Mexico", "plan_name": "United Health Care New Mexico", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Student Resources", "plan_name": "United Healthcare Student Resources", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Supplement", "plan_name": "United Healthcare Supplement", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "United Select Health", "plan_name": "United Select Health", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "United World Life", "plan_name": "United World Life", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Unity Health Insurance", "plan_name": "Unity Health Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "UPMC Health Plan", "plan_name": "UPMC Health Plan", "standard_charge_dollar": 1088.0, "methodology": "fee schedule" }, { "payer_name": "USAA Life Ins", "plan_name": "USAA Life Ins", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Valley Health Plan", "plan_name": "Valley Health Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Vantage Health Plans", "plan_name": "Vantage Health Plans", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Voans Senior Care Community Of Colo", "plan_name": "Voans Senior Care Community Of Colo", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "WEBB TPA", "plan_name": "WEBB TPA", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Wellcare Of Texas", "plan_name": "Wellcare Of Texas", "standard_charge_dollar": 771.0, "methodology": "fee schedule" }, { "payer_name": "Wellfleet", "plan_name": "Wellfleet", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "Winhealth", "plan_name": "Winhealth", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Woodmen Of The World Assured Life Associ", "plan_name": "Woodmen Of The World Assured Life Associ", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Wyoming Pace", "plan_name": "Wyoming Pace", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "ZURICH", "plan_name": "ZURICH", "standard_charge_dollar": 800.0, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "minimum": 600.0, "maximum": 1539.85 } ] }, { "description": "Acute Gero R&B", "code_information": [ { "code": "124", "type": "RC" }, { "code": "110000", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "AARP Health Care Options", "plan_name": "AARP Health Care Options", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "AFLAC Supplemental", "plan_name": "AFLAC Supplemental", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 840.0, "methodology": "fee schedule" }, { "payer_name": "Allell-Sunflower State Health Plan", "plan_name": "Allell-Sunflower State Health Plan", "standard_charge_dollar": 900.0, "methodology": 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schedule" }, { "payer_name": "American Continental Insurance Comapny", "plan_name": "American Continental Insurance Comapny", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "American Republic Corp Ins", "plan_name": "American Republic Corp Ins", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Amerigroup", "plan_name": "Amerigroup", "standard_charge_dollar": 771.0, "methodology": "fee schedule" }, { "payer_name": "AMFirst", "plan_name": "AMFirst", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Arizona Medicare", "plan_name": "Anthem BCBS Arizona Medicare", 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schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan Issuer-Medco", "plan_name": "APWU Health Plan Issuer-Medco", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Arapahoe County Dept Of Human Services", "plan_name": "Arapahoe County Dept Of Human Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Arise Health Plan", "plan_name": "Arise Health Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "ASI Tricare Retired Supplement", "plan_name": "ASI Tricare Retired Supplement", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "ASR Health", "plan_name": "ASR Health", "standard_charge_dollar": 972.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Auxiant - PHCS", "plan_name": "Auxiant - PHCS", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Avanta PHCS Verdegard Admin", "plan_name": "Avanta PHCS Verdegard Admin", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Bankers Fidelity", "plan_name": "Bankers Fidelity", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Bankers Life", "plan_name": "Bankers Life", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Baylor Scott & White", "plan_name": "Baylor Scott & White", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "BCBS HMO Colorado", "plan_name": "BCBS HMO Colorado", "standard_charge_dollar": 1092.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Ben-E-Lect", "plan_name": "Ben-E-Lect", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Benefit Management Inc", "plan_name": "Benefit Management Inc", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Bind Benefits, Inc", "plan_name": "Bind Benefits, Inc", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Blue Cross Blue Shield", "plan_name": "Blue Cross Blue Shield", "standard_charge_dollar": 1092.0, "methodology": "fee schedule" }, { "payer_name": "Blue Cross Community Centennial", "plan_name": "Blue Cross Community Centennial", 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"payer_name": "Combined Ins Of America", "plan_name": "Combined Ins Of America", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Commonwealth Care Alliance", "plan_name": "Commonwealth Care Alliance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Community Care", "plan_name": "Community Care", "standard_charge_dollar": 771.0, "methodology": "fee schedule" }, { "payer_name": "Community Health Options", "plan_name": "Community Health Options", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "ComPsych", "plan_name": "ComPsych", "standard_charge_dollar": 1040.0, "methodology": "fee schedule" }, { "payer_name": "Continental General Insurace", "plan_name": "Continental General Insurace", "standard_charge_dollar": 1004.0, "methodology": "fee schedule" }, { "payer_name": "Continental Insurance - Marpai Health", "plan_name": "Continental Insurance - Marpai Health", "standard_charge_dollar": 1034.0, "methodology": "fee schedule" }, { "payer_name": "Coordinated Benefit Plan", "plan_name": "Coordinated Benefit Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Costilla County DHS", "plan_name": "Costilla County DHS", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Coventry", "plan_name": "Coventry", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 1339.0, "methodology": "fee schedule" }, { "payer_name": "CSU Funding", "plan_name": "CSU Funding", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Dakatocare", "plan_name": "Dakatocare", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Dean Health Plans", "plan_name": "Dean Health Plans", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health DHHA", "plan_name": "Denver Health DHHA", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Elevate Silver", "plan_name": "Denver Health Elevate Silver", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Med Plan Cofinity", "plan_name": "Denver Health Med Plan Cofinity", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "DHS Weld County Dept Of Human Services", "plan_name": "DHS Weld County Dept Of Human Services", "standard_charge_dollar": 981.2, "methodology": "fee schedule" }, { "payer_name": "Easy Choice Health Plan", "plan_name": "Easy Choice Health Plan", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "Employer Benefit Service Inc.", "plan_name": "Employer Benefit Service Inc.", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Employers Health Network", "plan_name": "Employers Health Network", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "Enterprise Group Planning, Inc", "plan_name": "Enterprise Group Planning, Inc", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Equitable Life And Casualty Insurance Co", "plan_name": "Equitable Life And Casualty Insurance Co", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Equitable Plan Services", "plan_name": "Equitable Plan Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Evercare - Medicaid New Mexico", "plan_name": "Evercare - Medicaid New Mexico", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Excellus BCBS Medicare Advantage", "plan_name": "Excellus BCBS Medicare Advantage", "standard_charge_dollar": 771.0, "methodology": "fee schedule" }, { "payer_name": "FCBS", "plan_name": "FCBS", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "Federal Blue Cross", "plan_name": "Federal Blue Cross", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Fidelis - Medicare Advantage", "plan_name": "Fidelis - Medicare Advantage", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "First Care", "plan_name": "First Care", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "First Choice Health 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"GEHA", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Gerber Life Ins Company", "plan_name": "Gerber Life Ins Company", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "GHI", "plan_name": "GHI", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "GHI-BMP", "plan_name": "GHI-BMP", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 867.0, "methodology": "fee schedule" }, { "payer_name": "Gravie Admin Service Aetna", "plan_name": "Gravie Admin Service Aetna", "standard_charge_dollar": 1175.0, "methodology": "fee schedule" }, { "payer_name": "Great Southern Life Ins Co", "plan_name": "Great Southern Life Ins Co", 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"standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Health EZ", "plan_name": "Health EZ", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Health Management Concepts", "plan_name": "Health Management Concepts", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Commercial Claims", "plan_name": "Health Net Commercial Claims", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp Integrated Solutions LLC", "plan_name": "HealthComp Integrated Solutions LLC", "standard_charge_dollar": 1210.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope", "plan_name": "HealthScope", "standard_charge_dollar": 1034.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope 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"plan_name": "Huntsman Mental Health Institute - BHN", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "HWBS Claims", "plan_name": "HWBS Claims", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Illinicare Health Plan", "plan_name": "Illinicare Health Plan", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "ILWU-PMA Coastwise Claims", "plan_name": "ILWU-PMA Coastwise Claims", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Imagine 360 Administrators", "plan_name": "Imagine 360 Administrators", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "InnovAge Pace", "plan_name": "InnovAge Pace", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Insurance Management Inc", "plan_name": "Insurance Management Inc", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": 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Alternative Rural Hospital", "plan_name": "Kayenta Alternative Rural Hospital", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Kemper Insurance Benefits", "plan_name": "Kemper Insurance Benefits", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Kit Carson County", "plan_name": "Kit Carson County", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "LA Health Care Plan", "plan_name": "LA Health Care Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Larimer County DHS", "plan_name": "Larimer County DHS", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Liberty Healthshare", "plan_name": "Liberty Healthshare", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Life Shield STM - Ins TPA", "plan_name": "Life Shield STM - Ins TPA", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "LINECO Mental Health & Substance Abuse", "plan_name": "LINECO Mental Health & Substance Abuse", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Lucent Health", "plan_name": "Lucent Health", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "M-Care Medical Network", "plan_name": "M-Care Medical Network", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 1004.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Devoted Health Plans", "plan_name": "Magellan Devoted Health Plans", "standard_charge_dollar": 1060.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Health Services", "plan_name": "Magellan Health Services", "standard_charge_dollar": 1060.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Insurance", "plan_name": "Magellan Insurance", "standard_charge_dollar": 1060.0, "methodology": "fee schedule" }, { "payer_name": "Mailhandlers", "plan_name": "Mailhandlers", "standard_charge_dollar": 867.0, "methodology": "fee schedule" }, { "payer_name": "Managed Care Insurance - MBR Claims", "plan_name": "Managed Care Insurance - MBR Claims", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Network Group", "plan_name": "Managed Health Network Group", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Manhatten Life Supplemental", "plan_name": "Manhatten Life Supplemental", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Mayo Health Solutions", "plan_name": "Mayo Health Solutions", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Medcost Ultra", "plan_name": "Medcost Ultra", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Medica Elect", "plan_name": "Medica Elect", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Medical Mutual Ins", "plan_name": "Medical Mutual Ins", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "Medico Insurance Supplement", "plan_name": "Medico Insurance Supplement", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 1140.3, "methodology": "fee schedule" }, { "payer_name": "Meritain Health- Aetna Choice POS", "plan_name": "Meritain Health- Aetna Choice POS", "standard_charge_dollar": 1210.0, "methodology": "fee 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Attn Claims", "plan_name": "Nova Healthcare - Attn Claims", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "OHIO Casualty", "plan_name": "OHIO Casualty", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Old Surety Life Ins", "plan_name": "Old Surety Life Ins", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Optima Health Plans", "plan_name": "Optima Health Plans", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "OPTUM EMPIRE HEALTH PLAN", "plan_name": "OPTUM EMPIRE HEALTH PLAN", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "Optum Health Behavioral Solutions", "plan_name": "Optum Health Behavioral Solutions", "standard_charge_dollar": 867.0, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 1065.0, "methodology": "fee schedule" }, { "payer_name": "Pacific Source Health Plan", "plan_name": "Pacific Source Health Plan", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Pacificare Behavioral Health", "plan_name": "Pacificare Behavioral Health", "standard_charge_dollar": 902.0, "methodology": "fee schedule" }, { "payer_name": "PAI Claims Processing", "plan_name": "PAI Claims Processing", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "ParkCare Plus", "plan_name": "ParkCare Plus", "standard_charge_dollar": 980.0, "methodology": "fee schedule" }, { "payer_name": "Peak Administration", "plan_name": "Peak Administration", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Peak PPA", "plan_name": "Peak PPA", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Penrose Hospital", "plan_name": "Penrose Hospital", "standard_charge_dollar": 875.0, "methodology": "fee schedule" }, { "payer_name": "PHCS - The Health Plan", "plan_name": "PHCS - The Health Plan", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Physicians Mutual Insurance Company", "plan_name": "Physicians Mutual Insurance Company", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Pinnacol Assurance", "plan_name": "Pinnacol Assurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Preferred One Administrative Services", "plan_name": "Preferred One Administrative Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Presbyterian Health Plan", "plan_name": "Presbyterian Health Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Priority Health Insurance", "plan_name": "Priority Health Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Private Health Care Systems", "plan_name": "Private Health Care Systems", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Professional Benefit Administrators", "plan_name": "Professional Benefit Administrators", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Progressive Group Of Insurance Comp", "plan_name": "Progressive Group Of Insurance Comp", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Provider Network Of America", "plan_name": "Provider Network Of America", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Psych Care", "plan_name": "Psych Care", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Public Employees Health Program", "plan_name": "Public Employees Health Program", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Pueblo County DHS", "plan_name": "Pueblo County DHS", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Pyramid Life", "plan_name": "Pyramid Life", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Redirect Health - Multiplan", "plan_name": "Redirect Health - Multiplan", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "Regional Care Inc", "plan_name": "Regional Care Inc", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Reserve National", "plan_name": "Reserve National", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Reserve Officers Assoc Insurance", "plan_name": "Reserve Officers Assoc Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Rio Blanco County DHS", "plan_name": "Rio Blanco County DHS", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "RMHP Commercial Optun", "plan_name": "RMHP Commercial Optun", "standard_charge_dollar": 1539.85, "methodology": "fee schedule" }, { "payer_name": "RMHP HMO Optum", "plan_name": "RMHP HMO Optum", "standard_charge_dollar": 1539.85, "methodology": "fee schedule" }, { "payer_name": "RMHP Medicare Optum", "plan_name": "RMHP Medicare Optum", "standard_charge_dollar": 813.0, "methodology": "fee schedule" }, { "payer_name": "RMSCO, Inc", "plan_name": "RMSCO, Inc", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Health Plans Medicaid", "plan_name": "Rocky Mountain Health Plans Medicaid", "standard_charge_dollar": 1150.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Pace", "plan_name": "Rocky Mountain Pace", "standard_charge_dollar": 814.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain-Life Strategies", "plan_name": "Rocky Mountain-Life Strategies", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mtn Pace", "plan_name": "Rocky Mtn Pace", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Routt County Jail & Detention Center", "plan_name": "Routt County Jail & Detention Center", "standard_charge_dollar": 1500.0, "methodology": "fee schedule" }, { "payer_name": "Safeco Ins Of America", "plan_name": "Safeco Ins Of America", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sanford Health Ins - Multiplan", "plan_name": "Sanford Health Ins - Multiplan", "standard_charge_dollar": 825.0, "methodology": "fee schedule" }, { "payer_name": "Scan Healthcare Of Arizona", "plan_name": "Scan Healthcare Of Arizona", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Scott-White Health Plans", "plan_name": "Scott-White Health Plans", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "SECURE HORIZONS", "plan_name": "SECURE HORIZONS", "standard_charge_dollar": 850.0, 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"standard_charge_dollar": 902.0, "methodology": "fee schedule" }, { "payer_name": "Sentinel Life Insurance", "plan_name": "Sentinel Life Insurance", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sentinel Security Life", "plan_name": "Sentinel Security Life", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sentinel Security Life Ins Company", "plan_name": "Sentinel Security Life Ins Company", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sharp Community Med Grp/Secure Horizon", "plan_name": "Sharp Community Med Grp/Secure Horizon", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sheet Metal Workers", "plan_name": "Sheet Metal Workers", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Shelter Point", "plan_name": "Shelter Point", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": 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Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", 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"standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care 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"methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", 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schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 435.6, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", 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"payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 227.92, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "minimum": 90.09, "maximum": 500.0 } ] }, { "description": "Tri/Medi Child/Adol PHP ED - 4 units", "code_information": [ { "code": "G0177", "type": "HCPCS" }, { "code": "2024", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { 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"methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Carelon Medicare Advantage", "plan_name": "Carelon Medicare Advantage", "standard_charge_dollar": 67.57, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 227.92, "methodology": 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"standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "Network Health VA", "plan_name": "Network Health VA", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Nevada Mediblue Plus HMO", "plan_name": "Nevada Mediblue Plus HMO", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Northeast HP- RMHP", "plan_name": "Northeast HP- RMHP", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Nova Healthcare - Attn Claims", "plan_name": "Nova Healthcare - Attn Claims", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "Pacific Source Health Plan", "plan_name": "Pacific Source Health Plan", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "ParkCare Plus", "plan_name": "ParkCare Plus", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Priority Health Insurance", "plan_name": "Priority Health Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Provider Network Of America", "plan_name": "Provider Network Of America", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Pueblo County DHS", "plan_name": "Pueblo County DHS", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Redirect Health - Multiplan", "plan_name": "Redirect Health - Multiplan", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "Rio Blanco County DHS", "plan_name": "Rio Blanco County DHS", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "RMHP Commercial Optun", "plan_name": "RMHP Commercial Optun", "standard_charge_dollar": 1066.05, "methodology": "fee schedule" }, { "payer_name": "RMHP HMO Optum", "plan_name": "RMHP HMO Optum", "standard_charge_dollar": 1066.05, "methodology": "fee schedule" }, { "payer_name": "Routt County Jail & Detention Center", "plan_name": "Routt County Jail & Detention Center", "standard_charge_dollar": 1500.0, "methodology": "fee schedule" }, { "payer_name": "Sanford Health Ins - Multiplan", "plan_name": "Sanford Health Ins - Multiplan", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Insurance", "plan_name": "Select Health Insurance", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Medicare Adv", "plan_name": "Select Health Medicare Adv", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 902.0, "methodology": "fee schedule" }, { "payer_name": "Shelter Point", "plan_name": "Shelter Point", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Sierra Health & Life", "plan_name": "Sierra Health & Life", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Simplan Insurance", "plan_name": "Simplan Insurance", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "State Of Co Probation", "plan_name": "State Of Co Probation", "standard_charge_dollar": 1158.75, "methodology": "fee schedule" }, { "payer_name": "Surest - United Health Care", "plan_name": "Surest - United Health Care", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "Teller County DHS", "plan_name": "Teller County DHS", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Thrivent Medicare Supplement", "plan_name": "Thrivent Medicare Supplement", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "TLC Benefits Solution Inc.", "plan_name": "TLC Benefits Solution Inc.", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 1226.0, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 1156.0, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 1156.0, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 1156.0, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 1156.0, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 1156.0, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 1156.0, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 1480.0, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 1004.0, "methodology": "fee schedule" }, { "payer_name": "Tufts Health Plan", "plan_name": "Tufts Health Plan", "standard_charge_dollar": 1072.0, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care New Mexico", "plan_name": "United Health Care New Mexico", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Student Resources", "plan_name": "United Healthcare Student Resources", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Supplement", "plan_name": "United Healthcare Supplement", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "United Select Health", "plan_name": "United Select Health", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "United World Life", "plan_name": "United World Life", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "UPMC Health Plan", "plan_name": "UPMC Health Plan", "standard_charge_dollar": 1088.0, "methodology": "fee schedule" }, { "payer_name": "Voans Senior Care Community Of Colo", "plan_name": "Voans Senior Care Community Of Colo", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Wellfleet", "plan_name": "Wellfleet", "standard_charge_dollar": 950.0, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "minimum": 677.67, "maximum": 1600.0 } ] }, { "description": "I/P Residential Stay", "code_information": [ { "code": "610002", "type": "RC" }, { "code": "610002", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health Strategies", "plan_name": "Carelon Behavioral Health Strategies", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH APWU", "plan_name": "Carelon BH APWU", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Employee Asst", "plan_name": "Carelon BH Employee Asst", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Great West", "plan_name": "Carelon BH Great West", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Health Colorado Medicaid", "plan_name": "Carelon Health Colorado Medicaid", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "MHNET", "plan_name": "MHNET", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Psych Care", "plan_name": "Psych Care", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "SECURE HORIZONS", "plan_name": "SECURE HORIZONS", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Sharp Community Med Grp/Secure Horizon", "plan_name": "Sharp Community Med Grp/Secure Horizon", "standard_charge_dollar": 800.0, "methodology": "fee schedule" } ], "minimum": 800.0, "maximum": 800.0 } ] }, { "description": "ECT", "code_information": [ { "code": "90870", "type": "CPT" }, { "code": "200200", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "AARP Health Care Options", "plan_name": "AARP Health Care Options", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 975.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 975.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 975.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 975.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 975.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 700.0, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 502.33, "methodology": "fee schedule" }, { "payer_name": "Allsavers", "plan_name": "Allsavers", "standard_charge_dollar": 1001.0, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 700.0, "methodology": "fee schedule" }, { "payer_name": "American Continental Insurance Comapny", "plan_name": "American Continental Insurance Comapny", "standard_charge_dollar": 700.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 700.0, "methodology": "fee schedule" }, { "payer_name": "American Republic Corp Ins", "plan_name": "American Republic Corp Ins", "standard_charge_dollar": 834.0, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 700.0, "methodology": "fee schedule" }, { "payer_name": "AMFirst", "plan_name": "AMFirst", "standard_charge_dollar": 1001.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 493.27, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 925.97, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 925.97, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 925.97, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 925.97, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 925.97, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan Issuer-Medco", "plan_name": "APWU Health Plan Issuer-Medco", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Arapahoe County Dept Of Human Services", "plan_name": "Arapahoe County Dept Of Human Services", "standard_charge_dollar": 700.0, "methodology": "fee schedule" }, { "payer_name": "ASI Tricare Retired Supplement", "plan_name": "ASI Tricare Retired Supplement", "standard_charge_dollar": 700.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 700.0, "methodology": "fee schedule" }, { "payer_name": "Bankers Life", "plan_name": "Bankers Life", "standard_charge_dollar": 700.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 700.0, "methodology": "fee schedule" }, { "payer_name": "Baylor Scott & White", "plan_name": "Baylor Scott & White", "standard_charge_dollar": 1001.0, "methodology": "fee schedule" }, { "payer_name": "BCBS HMO Colorado", "plan_name": "BCBS HMO Colorado", "standard_charge_dollar": 873.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 700.0, "methodology": "fee schedule" }, { "payer_name": "Bind Benefits, Inc", "plan_name": "Bind Benefits, Inc", "standard_charge_dollar": 816.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Bright Health Management", "plan_name": "Bright Health Management", "standard_charge_dollar": 1273.0, "methodology": "fee schedule" }, { "payer_name": "Bright Health Medicare Advantage", "plan_name": "Bright Health Medicare Advantage", "standard_charge_dollar": 1273.0, "methodology": "fee schedule" }, { "payer_name": "Broadspire", "plan_name": "Broadspire", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 803.4, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health Strategies", "plan_name": "Carelon Behavioral Health Strategies", "standard_charge_dollar": 803.4, "methodology": "fee schedule" }, { "payer_name": "Carelon BH APWU", "plan_name": "Carelon BH APWU", "standard_charge_dollar": 803.4, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Employee Asst", "plan_name": "Carelon BH Employee Asst", "standard_charge_dollar": 803.4, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Great West", "plan_name": "Carelon BH Great West", "standard_charge_dollar": 803.4, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 803.4, "methodology": "fee schedule" }, { "payer_name": "Carelon Health Colorado Medicaid", "plan_name": "Carelon Health Colorado Medicaid", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Medicare Advantage", "plan_name": "Carelon Medicare Advantage", "standard_charge_dollar": 803.4, "methodology": "fee schedule" }, { "payer_name": "Carelon Northeast Health Partners Mcaid", "plan_name": "Carelon Northeast Health Partners Mcaid", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 898.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Alliance Health And Life", "plan_name": "Cigna Alliance Health And Life", "standard_charge_dollar": 898.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 898.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Health Spring Medicare Advantage", "plan_name": "Cigna Health Spring Medicare Advantage", "standard_charge_dollar": 898.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 898.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Supplemental", "plan_name": "Cigna Supplemental", "standard_charge_dollar": 898.0, "methodology": "fee schedule" }, { "payer_name": "Cigna True Choice Medicare PPO", "plan_name": "Cigna True Choice Medicare PPO", "standard_charge_dollar": 898.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Zenith Administrators", "plan_name": "Cigna Zenith Administrators", "standard_charge_dollar": 898.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 898.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 898.0, "methodology": "fee schedule" }, { "payer_name": "Clear Springs Health Inc", "plan_name": "Clear Springs Health Inc", "standard_charge_dollar": 477.01, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 810.0, "methodology": "fee schedule" }, { "payer_name": "Colo Community Health Alliance", "plan_name": "Colo Community Health Alliance", "standard_charge_dollar": 832.0, "methodology": "fee schedule" }, { "payer_name": "Colonial Penn Med Supplement", "plan_name": "Colonial Penn Med Supplement", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 997.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 624.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access CHP+", "plan_name": "Colorado Access CHP+", "standard_charge_dollar": 997.0, "methodology": "fee schedule" }, { "payer_name": "ComPsych", "plan_name": "ComPsych", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Continental Insurance - Marpai Health", "plan_name": "Continental Insurance - Marpai Health", "standard_charge_dollar": 859.0, "methodology": "fee schedule" }, { "payer_name": "Coordinated Benefit Plan", "plan_name": "Coordinated Benefit Plan", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health DHHA", "plan_name": "Denver Health DHHA", "standard_charge_dollar": 700.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Elevate Silver", "plan_name": "Denver Health Elevate Silver", "standard_charge_dollar": 1001.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Med Plan Cofinity", "plan_name": "Denver Health Med Plan Cofinity", 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"plan_name": "Cigna Health Spring Medicare Advantage", "standard_charge_dollar": 261.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 261.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Supplemental", "plan_name": "Cigna Supplemental", "standard_charge_dollar": 261.0, "methodology": "fee schedule" }, { "payer_name": "Cigna True Choice Medicare PPO", "plan_name": "Cigna True Choice Medicare PPO", "standard_charge_dollar": 261.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Zenith Administrators", "plan_name": "Cigna Zenith Administrators", "standard_charge_dollar": 261.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 261.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 261.0, "methodology": "fee schedule" }, { "payer_name": "Continental Insurance - Marpai Health", "plan_name": "Continental Insurance - Marpai Health", "standard_charge_dollar": 258.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 258.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 180.0, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 133.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health- Aetna Choice POS", "plan_name": "Meritain Health- Aetna Choice POS", "standard_charge_dollar": 243.0, "methodology": "fee schedule" }, { "payer_name": "Optum Health Behavioral Solutions", "plan_name": "Optum Health Behavioral Solutions", "standard_charge_dollar": 133.0, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 133.0, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 133.0, "methodology": "fee schedule" }, { "payer_name": "Simplan Insurance", "plan_name": "Simplan Insurance", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Starmark Insurance", "plan_name": "Starmark Insurance", "standard_charge_dollar": 243.0, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 243.0, "methodology": "fee schedule" }, { "payer_name": "Tufts Health Plan", "plan_name": "Tufts Health Plan", "standard_charge_dollar": 257.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 133.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "UPMC Health Plan", "plan_name": "UPMC Health Plan", "standard_charge_dollar": 261.0, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "minimum": 133.0, "maximum": 261.0 } ] }, { "description": "Gero Psych IOP 3 hrs", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "6350", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 243.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 243.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 243.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 243.0, "methodology": "fee schedule" }, { "payer_name": "Allsavers", "plan_name": "Allsavers", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "American Republic Corp Ins", "plan_name": "American Republic Corp Ins", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "AMFirst", "plan_name": "AMFirst", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 226.84, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "ASR Health", "plan_name": "ASR Health", "standard_charge_dollar": 231.0, "methodology": "fee schedule" }, { "payer_name": "Baylor Scott & White", "plan_name": "Baylor Scott & White", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "BCBS HMO Colorado", "plan_name": "BCBS HMO Colorado", "standard_charge_dollar": 218.0, "methodology": "fee schedule" }, { "payer_name": "Ben-E-Lect", "plan_name": "Ben-E-Lect", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Blue Cross Blue Shield", "plan_name": "Blue Cross Blue Shield", "standard_charge_dollar": 218.0, "methodology": "fee schedule" }, { "payer_name": "Bright Health Management", "plan_name": "Bright Health Management", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 229.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Health Colorado Medicaid", "plan_name": "Carelon Health Colorado Medicaid", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Northeast Health Partners Mcaid", "plan_name": "Carelon Northeast Health Partners Mcaid", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Alliance Health And Life", "plan_name": "Cigna Alliance Health And Life", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Health Spring Medicare Advantage", "plan_name": "Cigna Health Spring Medicare Advantage", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Supplemental", "plan_name": "Cigna Supplemental", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna True Choice Medicare PPO", "plan_name": "Cigna True Choice Medicare PPO", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Zenith Administrators", "plan_name": "Cigna Zenith Administrators", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Colo Community Health Alliance", "plan_name": "Colo Community Health Alliance", "standard_charge_dollar": 312.12, "methodology": "fee schedule" }, { "payer_name": "ComPsych", "plan_name": "ComPsych", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Continental Insurance - Marpai Health", "plan_name": "Continental Insurance - Marpai Health", "standard_charge_dollar": 258.0, "methodology": "fee schedule" }, { "payer_name": "Coventry", "plan_name": "Coventry", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Dean Health Plans", "plan_name": "Dean Health Plans", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health DHHA", "plan_name": "Denver Health DHHA", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Elevate Silver", "plan_name": "Denver Health Elevate Silver", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Med Plan Cofinity", "plan_name": "Denver Health Med Plan Cofinity", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Enterprise Group Planning, Inc", "plan_name": "Enterprise Group Planning, Inc", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Federal Blue Cross", "plan_name": "Federal Blue Cross", "standard_charge_dollar": 225.0, "methodology": "fee schedule" }, { "payer_name": "First Choice Health Network", "plan_name": "First Choice Health Network", "standard_charge_dollar": 449.0, "methodology": "fee schedule" }, { "payer_name": "Friday Health Plans", "plan_name": "Friday Health Plans", "standard_charge_dollar": 321.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "HCA Optum", "plan_name": "HCA Optum", "standard_charge_dollar": 150.0, "methodology": "fee schedule" }, { "payer_name": "Health Alliance", "plan_name": "Health Alliance", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 258.0, "methodology": "fee schedule" }, { "payer_name": "Houston Casualty Co", "plan_name": "Houston Casualty Co", "standard_charge_dollar": 220.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 226.84, "methodology": "fee schedule" }, { "payer_name": "Huntsman Mental Health Institute - BHN", "plan_name": "Huntsman Mental Health Institute - BHN", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Imagine 360 Administrators", "plan_name": "Imagine 360 Administrators", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Liberty Healthshare", "plan_name": "Liberty Healthshare", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Devoted Health Plans", "plan_name": "Magellan Devoted Health Plans", "standard_charge_dollar": 219.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Health Services", "plan_name": "Magellan Health Services", "standard_charge_dollar": 219.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Insurance", "plan_name": "Magellan Insurance", "standard_charge_dollar": 219.0, "methodology": "fee schedule" }, { "payer_name": "Mailhandlers", "plan_name": "Mailhandlers", "standard_charge_dollar": 134.0, "methodology": "fee schedule" }, { "payer_name": "Mayo Health Solutions", "plan_name": "Mayo Health Solutions", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Medica Elect", "plan_name": "Medica Elect", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health- Aetna Choice POS", "plan_name": "Meritain Health- Aetna Choice POS", "standard_charge_dollar": 243.0, "methodology": "fee schedule" }, { "payer_name": "Mines And Associates, PC", "plan_name": "Mines And Associates, PC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Modern Assistance Program", "plan_name": "Modern Assistance Program", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Of Texas", "plan_name": "Molina Healthcare Of Texas", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Motivhealth", "plan_name": "Motivhealth", "standard_charge_dollar": 157.0, "methodology": "fee schedule" }, { "payer_name": "Mountain Health Co-op", "plan_name": "Mountain Health Co-op", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "New Mexico Medicaid", "plan_name": "New Mexico Medicaid", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Northeast HP- RMHP", "plan_name": "Northeast HP- RMHP", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Optum Health Behavioral Solutions", "plan_name": "Optum Health Behavioral Solutions", "standard_charge_dollar": 133.0, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Pacificare Behavioral Health", "plan_name": "Pacificare Behavioral Health", "standard_charge_dollar": 140.0, "methodology": "fee schedule" }, { "payer_name": "ParkCare Plus", "plan_name": "ParkCare Plus", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Provider Network Of America", "plan_name": "Provider Network Of America", "standard_charge_dollar": 324.77, "methodology": "fee schedule" }, { "payer_name": "RMHP Medicare Optum", "plan_name": "RMHP Medicare Optum", "standard_charge_dollar": 232.0, "methodology": "fee schedule" }, { "payer_name": "Routt County Jail & Detention Center", "plan_name": "Routt County Jail & Detention Center", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons Direct", "plan_name": "Secure Horizons Direct", "standard_charge_dollar": 140.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Insurance", "plan_name": "Select Health Insurance", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Medicare Adv", "plan_name": "Select Health Medicare Adv", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 140.0, "methodology": "fee schedule" }, { "payer_name": "Shelter Point", "plan_name": "Shelter Point", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Simplan Insurance", "plan_name": "Simplan Insurance", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Simplified Benefits Administrators", "plan_name": "Simplified Benefits Administrators", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Starmark Insurance", "plan_name": "Starmark Insurance", "standard_charge_dollar": 243.0, "methodology": "fee schedule" }, { "payer_name": "State Of Co Probation", "plan_name": "State Of Co Probation", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "Surest - United Health Care", "plan_name": "Surest - United Health Care", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Trans America Ins", "plan_name": "Trans America Ins", "standard_charge_dollar": 220.0, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 243.0, "methodology": "fee schedule" }, { "payer_name": "Tufts Health Plan", "plan_name": "Tufts Health Plan", "standard_charge_dollar": 257.0, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care New Mexico", "plan_name": "United Health Care New Mexico", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Student Resources", "plan_name": "United Healthcare Student Resources", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Supplement", "plan_name": "United Healthcare Supplement", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Select Health", "plan_name": "United Select Health", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United World Life", "plan_name": "United World Life", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "UPMC Health Plan", "plan_name": "UPMC Health Plan", "standard_charge_dollar": 261.0, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "minimum": 133.0, "maximum": 600.0 } ] }, { "description": "IOP Adult Daily Rate", "code_information": [ { "code": "S9480", "type": "HCPCS" }, { "code": "53000", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Allied Benefits Systems", "plan_name": "Allied Benefits Systems", "standard_charge_dollar": 205.0, "methodology": "fee schedule" }, { "payer_name": "Allsavers", "plan_name": "Allsavers", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "AMFirst", "plan_name": "AMFirst", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 225.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Arapahoe County Dept Of Human Services", "plan_name": "Arapahoe County Dept Of Human Services", "standard_charge_dollar": 150.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Baylor Scott & White", "plan_name": "Baylor Scott & White", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "BCBS HMO Colorado", "plan_name": "BCBS HMO Colorado", "standard_charge_dollar": 218.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Bind Benefits, Inc", "plan_name": "Bind Benefits, Inc", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Blue Cross Blue Shield", "plan_name": "Blue Cross Blue Shield", "standard_charge_dollar": 218.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Bright Health Management", "plan_name": "Bright Health Management", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "Bright Health Medicare Advantage", "plan_name": "Bright Health Medicare Advantage", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health Strategies", "plan_name": "Carelon Behavioral Health Strategies", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon BH APWU", "plan_name": "Carelon BH APWU", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Employee Asst", "plan_name": "Carelon BH Employee Asst", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Great West", "plan_name": "Carelon BH Great West", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon Health Colorado Medicaid", "plan_name": "Carelon Health Colorado Medicaid", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Medicare Advantage", "plan_name": "Carelon Medicare Advantage", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon Northeast Health Partners Mcaid", "plan_name": "Carelon Northeast Health Partners Mcaid", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Alliance Health And Life", "plan_name": "Cigna Alliance Health And Life", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Health Spring Medicare Advantage", "plan_name": "Cigna Health Spring Medicare Advantage", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Supplemental", "plan_name": "Cigna Supplemental", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna True Choice Medicare PPO", "plan_name": "Cigna True Choice Medicare PPO", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Zenith Administrators", "plan_name": "Cigna Zenith Administrators", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 243.0, "methodology": "fee schedule" }, { "payer_name": "Colo Community Health Alliance", "plan_name": "Colo Community Health Alliance", "standard_charge_dollar": 312.12, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 367.5, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 208.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access CHP+", "plan_name": "Colorado Access CHP+", "standard_charge_dollar": 367.5, "methodology": "fee schedule" }, { "payer_name": "ComPsych", "plan_name": "ComPsych", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Continental Insurance - Marpai Health", "plan_name": "Continental Insurance - Marpai Health", "standard_charge_dollar": 258.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 300.02, "methodology": "fee schedule" }, { "payer_name": "Dean Health Plans", "plan_name": "Dean Health Plans", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health DHHA", "plan_name": "Denver Health DHHA", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Elevate Silver", "plan_name": "Denver Health Elevate Silver", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Med Plan Cofinity", "plan_name": "Denver Health Med Plan Cofinity", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Employers Health Network", "plan_name": "Employers Health Network", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Enterprise Group Planning, Inc", "plan_name": "Enterprise Group Planning, Inc", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Equitable Life And Casualty Insurance Co", "plan_name": "Equitable Life And Casualty Insurance Co", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Equitable Plan Services", "plan_name": "Equitable Plan Services", "standard_charge_dollar": 225.0, "methodology": "fee schedule" }, { "payer_name": "Evercare - Medicaid New Mexico", "plan_name": "Evercare - Medicaid New Mexico", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Federal Blue Cross", "plan_name": "Federal Blue Cross", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "First Choice Health Network", "plan_name": "First Choice Health Network", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Friday Health Plans", "plan_name": "Friday Health Plans", "standard_charge_dollar": 321.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 130.0, "methodology": "fee schedule" }, { "payer_name": "Gravie Admin Service Aetna", "plan_name": "Gravie Admin Service Aetna", "standard_charge_dollar": 293.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "HAP Aetna", "plan_name": "HAP Aetna", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Harvard Pilgrim HealthCare", "plan_name": "Harvard Pilgrim HealthCare", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "HCA Optum", "plan_name": "HCA Optum", "standard_charge_dollar": 150.0, "methodology": "fee schedule" }, { "payer_name": "Health Alliance", "plan_name": "Health Alliance", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Health Management Concepts", "plan_name": "Health Management Concepts", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Commercial Claims", "plan_name": "Health Net Commercial Claims", "standard_charge_dollar": 229.0, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp Integrated Solutions LLC", "plan_name": "HealthComp Integrated Solutions LLC", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 258.0, "methodology": "fee schedule" }, { "payer_name": "Hemet Community Medical Group", "plan_name": "Hemet Community Medical Group", "standard_charge_dollar": 130.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 166.34, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 180.0, "methodology": "fee schedule" }, { "payer_name": "Huntsman Mental Health Institute - BHN", "plan_name": "Huntsman Mental Health Institute - BHN", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "HWBS Claims", "plan_name": "HWBS Claims", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Imagine 360 Administrators", "plan_name": "Imagine 360 Administrators", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente", "plan_name": "Kaiser Permanente", "standard_charge_dollar": 185.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Denver", "plan_name": "Kaiser Permanente Denver", "standard_charge_dollar": 185.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Northern", "plan_name": "Kaiser Permanente Northern", "standard_charge_dollar": 185.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Senior Advantage HMO", "plan_name": "Kaiser Permanente Senior Advantage HMO", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "Liberty Healthshare", "plan_name": "Liberty Healthshare", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Life Shield STM - Ins TPA", "plan_name": "Life Shield STM - Ins TPA", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "LINECO Mental Health & Substance Abuse", "plan_name": "LINECO Mental Health & Substance Abuse", "standard_charge_dollar": 229.0, "methodology": "fee schedule" }, { "payer_name": "Lucent Health", "plan_name": "Lucent Health", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "M-Care Medical Network", "plan_name": "M-Care Medical Network", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Devoted Health Plans", "plan_name": "Magellan Devoted Health Plans", "standard_charge_dollar": 219.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Health Services", "plan_name": "Magellan Health Services", "standard_charge_dollar": 219.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Insurance", "plan_name": "Magellan Insurance", "standard_charge_dollar": 219.0, "methodology": "fee schedule" }, { "payer_name": "Mailhandlers", "plan_name": "Mailhandlers", "standard_charge_dollar": 130.0, "methodology": "fee schedule" }, { "payer_name": "Managed Care Insurance - MBR Claims", "plan_name": "Managed Care Insurance - MBR Claims", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Network Group", "plan_name": "Managed Health Network Group", "standard_charge_dollar": 130.0, "methodology": "fee schedule" }, { "payer_name": "Medica Elect", "plan_name": "Medica Elect", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 284.55, "methodology": "fee schedule" }, { "payer_name": "Meritain Health- Aetna Choice POS", "plan_name": "Meritain Health- Aetna Choice POS", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "MERP Administrative Services", "plan_name": "MERP Administrative Services", "standard_charge_dollar": 130.0, "methodology": "fee schedule" }, { "payer_name": "MHNET", "plan_name": "MHNET", "standard_charge_dollar": 229.0, "methodology": "fee schedule" }, { "payer_name": "Mines And Associates, PC", "plan_name": "Mines And Associates, PC", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Mitchell International", "plan_name": "Mitchell International", "standard_charge_dollar": 130.0, "methodology": "fee schedule" }, { "payer_name": "Motivhealth", "plan_name": "Motivhealth", "standard_charge_dollar": 157.0, "methodology": "fee schedule" }, { "payer_name": "Mountain Health Co-op", "plan_name": "Mountain Health Co-op", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "Multiplan", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "MVP Healthcare Value Opts", "plan_name": "MVP Healthcare Value Opts", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "NALC Health Benefit Plan", "plan_name": "NALC Health Benefit Plan", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Nationwide Life", "plan_name": "Nationwide Life", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Neighborhood Health Plan", "plan_name": "Neighborhood Health Plan", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "New Mexico Medicaid", "plan_name": "New Mexico Medicaid", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Northeast HP- RMHP", "plan_name": "Northeast HP- RMHP", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "OPTUM EMPIRE HEALTH PLAN", "plan_name": "OPTUM EMPIRE HEALTH PLAN", "standard_charge_dollar": 130.0, "methodology": "fee schedule" }, { "payer_name": "Optum Health Behavioral Solutions", "plan_name": "Optum Health Behavioral Solutions", "standard_charge_dollar": 133.0, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Pacificare Behavioral Health", "plan_name": "Pacificare Behavioral Health", "standard_charge_dollar": 140.0, "methodology": "fee schedule" }, { "payer_name": "ParkCare Plus", "plan_name": "ParkCare Plus", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Physicians Mutual Insurance Company", "plan_name": "Physicians Mutual Insurance Company", "standard_charge_dollar": 229.0, "methodology": "fee schedule" }, { "payer_name": "Pinnacol Assurance", "plan_name": "Pinnacol Assurance", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Preferred One Administrative Services", "plan_name": "Preferred One Administrative Services", "standard_charge_dollar": 229.0, "methodology": "fee schedule" }, { "payer_name": "Presbyterian Health Plan", "plan_name": "Presbyterian Health Plan", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Private Health Care Systems", "plan_name": "Private Health Care Systems", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Provider Network Of America", "plan_name": "Provider Network Of America", "standard_charge_dollar": 324.77, "methodology": "fee schedule" }, { "payer_name": "Psych Care", "plan_name": "Psych Care", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Reserve Officers Assoc Insurance", "plan_name": "Reserve Officers Assoc Insurance", "standard_charge_dollar": 229.0, "methodology": "fee schedule" }, { "payer_name": "RMHP Commercial Optun", "plan_name": "RMHP Commercial Optun", "standard_charge_dollar": 710.7, "methodology": "fee schedule" }, { "payer_name": "RMHP HMO Optum", "plan_name": "RMHP HMO Optum", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "RMHP Medicare Optum", "plan_name": "RMHP Medicare Optum", "standard_charge_dollar": 232.0, "methodology": "fee schedule" }, { "payer_name": "RMSCO, Inc", "plan_name": "RMSCO, Inc", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Health Plans Medicaid", "plan_name": "Rocky Mountain Health Plans Medicaid", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Pace", "plan_name": "Rocky Mountain Pace", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain-Life Strategies", "plan_name": "Rocky Mountain-Life Strategies", "standard_charge_dollar": 130.0, "methodology": "fee schedule" }, { "payer_name": "Routt County Jail & Detention Center", "plan_name": "Routt County Jail & Detention Center", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Sanford Health Ins - Multiplan", "plan_name": "Sanford Health Ins - Multiplan", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "SECURE HORIZONS", "plan_name": "SECURE HORIZONS", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons (Medicare)", "plan_name": "Secure Horizons (Medicare)", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons Direct", "plan_name": "Secure Horizons Direct", "standard_charge_dollar": 140.0, "methodology": "fee schedule" }, { "payer_name": "Select Benefits Administrators", "plan_name": "Select Benefits Administrators", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Insurance", "plan_name": "Select Health Insurance", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Medicare Adv", "plan_name": "Select Health Medicare Adv", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 140.0, "methodology": "fee schedule" }, { "payer_name": "Selman Co", "plan_name": "Selman Co", "standard_charge_dollar": 130.0, "methodology": "fee schedule" }, { "payer_name": "Sentinel Life Insurance", "plan_name": "Sentinel Life Insurance", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Sharp Community Med Grp/Secure Horizon", "plan_name": "Sharp Community Med Grp/Secure Horizon", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Sheet Metal Workers", "plan_name": "Sheet Metal Workers", "standard_charge_dollar": 229.0, "methodology": "fee schedule" }, { "payer_name": "Shelter Point", "plan_name": "Shelter Point", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Simplan Insurance", "plan_name": "Simplan Insurance", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Simplified Benefits Administrators", "plan_name": "Simplified Benefits Administrators", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Standard Life And Accident Insurance", "plan_name": "Standard Life And Accident Insurance", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Starmark Insurance", "plan_name": "Starmark Insurance", "standard_charge_dollar": 243.0, "methodology": "fee schedule" }, { "payer_name": "State Of Co Probation", "plan_name": "State Of Co Probation", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "Surest - United Health Care", "plan_name": "Surest - United Health Care", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "The GEMGroup", "plan_name": "The GEMGroup", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "TLC Benefits Solution Inc.", "plan_name": "TLC Benefits Solution Inc.", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Trans America Ins", "plan_name": "Trans America Ins", "standard_charge_dollar": 220.0, "methodology": "fee schedule" }, { "payer_name": "Travelers Insurance", "plan_name": "Travelers Insurance", "standard_charge_dollar": 90.56, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Tufts Health Plan", "plan_name": "Tufts Health Plan", "standard_charge_dollar": 257.0, "methodology": "fee schedule" }, { "payer_name": "UHC COMMUNITY PLAN", "plan_name": "UHC COMMUNITY PLAN", "standard_charge_dollar": 133.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 140.0, "methodology": "fee schedule" }, { "payer_name": "UMR/CEBT-PM085516", "plan_name": "UMR/CEBT-PM085516", "standard_charge_dollar": 133.0, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care New Mexico", "plan_name": "United Health Care New Mexico", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Student Resources", "plan_name": "United Healthcare Student Resources", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Supplement", "plan_name": "United Healthcare Supplement", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Select Health", "plan_name": "United Select Health", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United World Life", "plan_name": "United World Life", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "UPMC Health Plan", "plan_name": "UPMC Health Plan", "standard_charge_dollar": 261.0, "methodology": "fee schedule" }, { "payer_name": "WEBB TPA", "plan_name": "WEBB TPA", "standard_charge_dollar": 130.0, "methodology": "fee schedule" }, { "payer_name": "Wellfleet", "plan_name": "Wellfleet", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Winhealth", "plan_name": "Winhealth", "standard_charge_dollar": 229.0, "methodology": "fee schedule" }, { "payer_name": "Wyoming Pace", "plan_name": "Wyoming Pace", "standard_charge_dollar": 178.8, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "minimum": 90.56, "maximum": 710.7 } ] }, { "description": "IOP Child/Adol", "code_information": [ { "code": "S9480", "type": "HCPCS" }, { "code": "53010", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Allsavers", "plan_name": "Allsavers", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "American Republic Corp Ins", "plan_name": "American Republic Corp Ins", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "AMFirst", "plan_name": "AMFirst", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 225.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "ASR Health", "plan_name": "ASR Health", "standard_charge_dollar": 231.0, "methodology": "fee schedule" }, { "payer_name": "Baylor Scott & White", "plan_name": "Baylor Scott & White", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "BCBS HMO Colorado", "plan_name": "BCBS HMO Colorado", "standard_charge_dollar": 218.0, "methodology": "fee schedule" }, { "payer_name": "Ben-E-Lect", "plan_name": "Ben-E-Lect", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Bind Benefits, Inc", "plan_name": "Bind Benefits, Inc", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Blue Cross Blue Shield", "plan_name": "Blue Cross Blue Shield", "standard_charge_dollar": 218.0, "methodology": "fee schedule" }, { "payer_name": "Bright Health Management", "plan_name": "Bright Health Management", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "Bright Health Medicare Advantage", "plan_name": "Bright Health Medicare Advantage", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health Strategies", "plan_name": "Carelon Behavioral Health Strategies", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon BH APWU", "plan_name": "Carelon BH APWU", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Employee Asst", "plan_name": "Carelon BH Employee Asst", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Great West", "plan_name": "Carelon BH Great West", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon Health Colorado Medicaid", "plan_name": "Carelon Health Colorado Medicaid", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Medicare Advantage", "plan_name": "Carelon Medicare Advantage", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon Northeast Health Partners Mcaid", "plan_name": "Carelon Northeast Health Partners Mcaid", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 48.14, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Alliance Health And Life", "plan_name": "Cigna Alliance Health And Life", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Health Spring Medicare Advantage", "plan_name": "Cigna Health Spring Medicare Advantage", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Supplemental", "plan_name": "Cigna Supplemental", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna True Choice Medicare PPO", "plan_name": "Cigna True Choice Medicare PPO", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Zenith Administrators", "plan_name": "Cigna Zenith Administrators", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 243.0, "methodology": "fee schedule" }, { "payer_name": "Colo Community Health Alliance", "plan_name": "Colo Community Health Alliance", "standard_charge_dollar": 312.12, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 367.5, "methodology": "fee schedule" }, { "payer_name": "Colorado Access CHP+", "plan_name": "Colorado Access CHP+", "standard_charge_dollar": 367.5, "methodology": "fee schedule" }, { "payer_name": "ComPsych", "plan_name": "ComPsych", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Continental Insurance - Marpai Health", "plan_name": "Continental Insurance - Marpai Health", "standard_charge_dollar": 258.0, "methodology": "fee schedule" }, { "payer_name": "Coventry", "plan_name": "Coventry", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Dean Health Plans", "plan_name": "Dean Health Plans", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health DHHA", "plan_name": "Denver Health DHHA", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Elevate Silver", "plan_name": "Denver Health Elevate Silver", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Med Plan Cofinity", "plan_name": "Denver Health Med Plan Cofinity", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Employers Health Network", "plan_name": "Employers Health Network", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Enterprise Group Planning, Inc", "plan_name": "Enterprise Group Planning, Inc", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Federal Blue Cross", "plan_name": "Federal Blue Cross", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "First Choice Health Network", "plan_name": "First Choice Health Network", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Friday Health Plans", "plan_name": "Friday Health Plans", "standard_charge_dollar": 321.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Gravie Admin Service Aetna", "plan_name": "Gravie Admin Service Aetna", "standard_charge_dollar": 293.0, "methodology": "fee schedule" }, { "payer_name": "HAP Aetna", "plan_name": "HAP Aetna", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "HCA Optum", "plan_name": "HCA Optum", "standard_charge_dollar": 150.0, "methodology": "fee schedule" }, { "payer_name": "Health Alliance", "plan_name": "Health Alliance", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Health Management Concepts", "plan_name": "Health Management Concepts", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp Integrated Solutions LLC", "plan_name": "HealthComp Integrated Solutions LLC", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 258.0, "methodology": "fee schedule" }, { "payer_name": "Houston Casualty Co", "plan_name": "Houston Casualty Co", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 180.0, "methodology": "fee schedule" }, { "payer_name": "Huntsman Mental Health Institute - BHN", "plan_name": "Huntsman Mental Health Institute - BHN", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Imagine 360 Administrators", "plan_name": "Imagine 360 Administrators", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Of Colorado", "plan_name": "Kaiser Of Colorado", "standard_charge_dollar": 229.0, "methodology": "fee schedule" }, { "payer_name": "Liberty Healthshare", "plan_name": "Liberty Healthshare", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Life Shield STM - Ins TPA", "plan_name": "Life Shield STM - Ins TPA", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Lucent Health", "plan_name": "Lucent Health", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Devoted Health Plans", "plan_name": "Magellan Devoted Health Plans", "standard_charge_dollar": 219.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Health Services", "plan_name": "Magellan Health Services", "standard_charge_dollar": 219.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Insurance", "plan_name": "Magellan Insurance", "standard_charge_dollar": 219.0, "methodology": "fee schedule" }, { "payer_name": "Mailhandlers", "plan_name": "Mailhandlers", "standard_charge_dollar": 130.0, "methodology": "fee schedule" }, { "payer_name": "Managed Care Insurance - MBR Claims", "plan_name": "Managed Care Insurance - MBR Claims", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Network Group", "plan_name": "Managed Health Network Group", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Mayo Health Solutions", "plan_name": "Mayo Health Solutions", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Medica Elect", "plan_name": "Medica Elect", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 284.55, "methodology": "fee schedule" }, { "payer_name": "Meritain Health- Aetna Choice POS", "plan_name": "Meritain Health- Aetna Choice POS", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Mines And Associates, PC", "plan_name": "Mines And Associates, PC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Motivhealth", "plan_name": "Motivhealth", "standard_charge_dollar": 157.0, "methodology": "fee schedule" }, { "payer_name": "Mountain Health Co-op", "plan_name": "Mountain Health Co-op", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "Multiplan", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "New Mexico Medicaid", "plan_name": "New Mexico Medicaid", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Northeast HP- RMHP", "plan_name": "Northeast HP- RMHP", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Optum Health Behavioral Solutions", "plan_name": "Optum Health Behavioral Solutions", "standard_charge_dollar": 260.0, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "ParkCare Plus", "plan_name": "ParkCare Plus", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Provider Network Of America", "plan_name": "Provider Network Of America", "standard_charge_dollar": 324.77, "methodology": "fee schedule" }, { "payer_name": "RMHP Commercial Optun", "plan_name": "RMHP Commercial Optun", "standard_charge_dollar": 618.0, "methodology": "fee schedule" }, { "payer_name": "Routt County Jail & Detention Center", "plan_name": "Routt County Jail & Detention Center", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Sanford Health Ins - Multiplan", "plan_name": "Sanford Health Ins - Multiplan", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Insurance", "plan_name": "Select Health Insurance", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Medicare Adv", "plan_name": "Select Health Medicare Adv", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 140.0, "methodology": "fee schedule" }, { "payer_name": "Shelter Point", "plan_name": "Shelter Point", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Simplan Insurance", "plan_name": "Simplan Insurance", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Simplified Benefits Administrators", "plan_name": "Simplified Benefits Administrators", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Starmark Insurance", "plan_name": "Starmark Insurance", "standard_charge_dollar": 243.0, "methodology": "fee schedule" }, { "payer_name": "State Of Co Probation", "plan_name": "State Of Co Probation", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "Surest - United Health Care", "plan_name": "Surest - United Health Care", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "TLC Benefits Solution Inc.", "plan_name": "TLC Benefits Solution Inc.", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Trans America Ins", "plan_name": "Trans America Ins", "standard_charge_dollar": 220.0, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Tufts Health Plan", "plan_name": "Tufts Health Plan", "standard_charge_dollar": 257.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 140.0, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care New Mexico", "plan_name": "United Health Care New Mexico", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Student Resources", "plan_name": "United Healthcare Student Resources", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Supplement", "plan_name": "United Healthcare Supplement", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Select Health", "plan_name": "United Select Health", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United World Life", "plan_name": "United World Life", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "UPMC Health Plan", "plan_name": "UPMC Health Plan", "standard_charge_dollar": 261.0, "methodology": "fee schedule" }, { "payer_name": "Wellfleet", "plan_name": "Wellfleet", "standard_charge_dollar": 250.0, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "minimum": 48.14, "maximum": 618.0 } ] }, { "description": "MCR IOP Adult - 1 Unit", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "52000", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { 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"standard_charge_dollar": 398.0, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 165.0, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "minimum": 165.0, "maximum": 450.0 } ] }, { "description": "Telehealth Tri/Medi Psych Adol IOP-1 unit", "code_information": [ { "code": "S9480", "type": "HCPCS" }, { "code": "816", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 398.0, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 398.0, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "minimum": 398.0, "maximum": 398.0 } ] }, { "description": "Tri Adol IOP - 1 unit", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "53021", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 208.39, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 398.0, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 162.0, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 398.0, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "minimum": 162.0, "maximum": 398.0 } ] }, { "description": "Tri Adol IOP - 2 unit", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "53022", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 85.36, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 199.0, "methodology": "fee schedule" } ], "gross_charge": 850.0, "minimum": 85.36, "maximum": 199.0 } ] }, { "description": "Tri Adol IOP - 3 unit", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "53023", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 56.91, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 132.67, "methodology": "fee schedule" } ], "gross_charge": 566.67, "minimum": 56.91, "maximum": 132.67 } ] }, { "description": "Tri Adult IOP - 1 unit", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "54001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 208.39, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 398.0, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 162.0, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 214.39, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "minimum": 162.0, "maximum": 398.0 } ] }, { "description": "Tri Adult IOP - 2 unit", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "54002", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 85.36, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 199.0, "methodology": "fee schedule" } ], "gross_charge": 850.0, "minimum": 85.36, "maximum": 199.0 } ] }, { "description": "Tri Adult IOP - 3 unit", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "54003", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 56.91, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 132.67, "methodology": "fee schedule" } ], "gross_charge": 566.67, "minimum": 56.91, "maximum": 132.67 } ] }, { "description": "Tri Gero IOP 1 unit", "code_information": [ { "code": "S9480", "type": "HCPCS" }, { "code": "6451", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 208.39, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 398.0, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 162.0, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 398.0, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "minimum": 162.0, "maximum": 398.0 } ] }, { "description": "Tri/Medi Gero IOP - 1 unit", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "6351", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 229.0, "methodology": "fee schedule" }, { "payer_name": "Clear Springs Health Inc", "plan_name": "Clear Springs Health Inc", "standard_charge_dollar": 231.45, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 201.26, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 170.21, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 231.45, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "minimum": 170.21, "maximum": 231.45 } ] }, { "description": "Adol CD IOP 3 hrs", "code_information": [ { "code": "H0015", "type": "HCPCS" }, { "code": "5300", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "ASR Health", "plan_name": "ASR Health", "standard_charge_dollar": 231.0, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "minimum": 231.0, "maximum": 231.0 } ] }, { "description": "IOP CD ADOL", "code_information": [ { "code": "H0015", "type": "HCPCS" }, { "code": "70002", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Allsavers", "plan_name": "Allsavers", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "American Republic Corp Ins", "plan_name": "American Republic Corp Ins", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "AMFirst", "plan_name": "AMFirst", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 225.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Baylor Scott & White", "plan_name": "Baylor Scott & White", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Bright Health Management", "plan_name": "Bright Health Management", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 229.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health Strategies", "plan_name": "Carelon Behavioral Health Strategies", "standard_charge_dollar": 229.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH APWU", "plan_name": "Carelon BH APWU", "standard_charge_dollar": 229.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Employee Asst", "plan_name": "Carelon BH Employee Asst", "standard_charge_dollar": 229.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Great West", "plan_name": "Carelon BH Great West", "standard_charge_dollar": 229.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Health Colorado Medicaid", "plan_name": "Carelon Health Colorado Medicaid", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Northeast Health Partners Mcaid", "plan_name": "Carelon Northeast Health Partners Mcaid", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 258.0, "methodology": "fee schedule" }, { "payer_name": "Colo Community Health Alliance", "plan_name": "Colo Community Health Alliance", "standard_charge_dollar": 312.12, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 367.5, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access CHP+", "plan_name": "Colorado Access CHP+", "standard_charge_dollar": 367.5, "methodology": "fee schedule" }, { "payer_name": "ComPsych", "plan_name": "ComPsych", "standard_charge_dollar": 289.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health DHHA", "plan_name": "Denver Health DHHA", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Elevate Silver", "plan_name": "Denver Health Elevate Silver", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Med Plan Cofinity", "plan_name": "Denver Health Med Plan Cofinity", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Employers Health Network", "plan_name": "Employers Health Network", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Enterprise Group Planning, Inc", "plan_name": "Enterprise Group Planning, Inc", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Federal Blue Cross", "plan_name": "Federal Blue Cross", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "First Choice Health Network", "plan_name": "First Choice Health Network", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Friday Health Plans", "plan_name": "Friday Health Plans", "standard_charge_dollar": 321.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Gravie Admin Service Aetna", "plan_name": "Gravie Admin Service Aetna", "standard_charge_dollar": 293.0, "methodology": "fee schedule" }, { "payer_name": "HAP Aetna", "plan_name": "HAP Aetna", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "HCA Optum", "plan_name": "HCA Optum", "standard_charge_dollar": 150.0, "methodology": "fee schedule" }, { "payer_name": "Health Alliance", "plan_name": "Health Alliance", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp Integrated Solutions LLC", "plan_name": "HealthComp Integrated Solutions LLC", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 198.0, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Huntsman Mental Health Institute - BHN", "plan_name": "Huntsman Mental Health Institute - BHN", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Imagine 360 Administrators", "plan_name": "Imagine 360 Administrators", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Liberty Healthshare", "plan_name": "Liberty Healthshare", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Lucent Health", "plan_name": "Lucent Health", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Medica Elect", "plan_name": "Medica Elect", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 284.55, "methodology": "fee schedule" }, { "payer_name": "Meritain Health- Aetna Choice POS", "plan_name": "Meritain Health- Aetna Choice POS", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Mines And Associates, PC", "plan_name": "Mines And Associates, PC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Motivhealth", "plan_name": "Motivhealth", "standard_charge_dollar": 157.0, "methodology": "fee schedule" }, { "payer_name": "Mountain Health Co-op", "plan_name": "Mountain Health Co-op", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "Multiplan", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Northeast HP- RMHP", "plan_name": "Northeast HP- RMHP", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Redirect Health - Multiplan", "plan_name": "Redirect Health - Multiplan", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "RMHP HMO Optum", "plan_name": "RMHP HMO Optum", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Routt County Jail & Detention Center", "plan_name": "Routt County Jail & Detention Center", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Sanford Health Ins - Multiplan", "plan_name": "Sanford Health Ins - Multiplan", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Insurance", "plan_name": "Select Health Insurance", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Medicare Adv", "plan_name": "Select Health Medicare Adv", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Shelter Point", "plan_name": "Shelter Point", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Simplified Benefits Administrators", "plan_name": "Simplified Benefits Administrators", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "State Of Co Probation", "plan_name": "State Of Co Probation", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "Surest - United Health Care", "plan_name": "Surest - United Health Care", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care New Mexico", "plan_name": "United Health Care New Mexico", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Student Resources", "plan_name": "United Healthcare Student Resources", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Supplement", "plan_name": "United Healthcare Supplement", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Select Health", "plan_name": "United Select Health", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United World Life", "plan_name": "United World Life", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Wellfleet", "plan_name": "Wellfleet", "standard_charge_dollar": 250.0, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "minimum": 150.0, "maximum": 450.0 } ] }, { "description": "IOP CD ADULT", "code_information": [ { "code": "H0015", "type": "HCPCS" }, { "code": "70001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Allsavers", "plan_name": "Allsavers", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "American Republic Corp Ins", "plan_name": "American Republic Corp Ins", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "AMFirst", "plan_name": "AMFirst", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 226.84, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Baylor Scott & White", "plan_name": "Baylor Scott & White", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Bright Health Management", "plan_name": "Bright Health Management", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health Strategies", "plan_name": "Carelon Behavioral Health Strategies", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon BH APWU", "plan_name": "Carelon BH APWU", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Employee Asst", "plan_name": "Carelon BH Employee Asst", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Great West", "plan_name": "Carelon BH Great West", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon Health Colorado Medicaid", "plan_name": "Carelon Health Colorado Medicaid", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Medicare Advantage", "plan_name": "Carelon Medicare Advantage", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon Northeast Health Partners Mcaid", "plan_name": "Carelon Northeast Health Partners Mcaid", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Alliance Health And Life", "plan_name": "Cigna Alliance Health And Life", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Health Spring Medicare Advantage", "plan_name": "Cigna Health Spring Medicare Advantage", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Supplemental", "plan_name": "Cigna Supplemental", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna True Choice Medicare PPO", "plan_name": "Cigna True Choice Medicare PPO", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Zenith Administrators", "plan_name": "Cigna Zenith Administrators", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Clear Springs Health Inc", "plan_name": "Clear Springs Health Inc", "standard_charge_dollar": 231.45, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 258.0, "methodology": "fee schedule" }, { "payer_name": "Colo Community Health Alliance", "plan_name": "Colo Community Health Alliance", "standard_charge_dollar": 312.12, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 367.5, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access CHP+", "plan_name": "Colorado Access CHP+", "standard_charge_dollar": 367.5, "methodology": "fee schedule" }, { "payer_name": "ComPsych", "plan_name": "ComPsych", "standard_charge_dollar": 289.0, "methodology": "fee schedule" }, { "payer_name": "Continental Insurance - Marpai Health", "plan_name": "Continental Insurance - Marpai Health", "standard_charge_dollar": 258.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health DHHA", "plan_name": "Denver Health DHHA", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Elevate Silver", "plan_name": "Denver Health Elevate Silver", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Med Plan Cofinity", "plan_name": "Denver Health Med Plan Cofinity", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Employers Health Network", "plan_name": "Employers Health Network", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Enterprise Group Planning, Inc", "plan_name": "Enterprise Group Planning, Inc", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Federal Blue Cross", "plan_name": "Federal Blue Cross", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "First Choice Health Network", "plan_name": "First Choice Health Network", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Friday Health Plans", "plan_name": "Friday Health Plans", "standard_charge_dollar": 321.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Gravie Admin Service Aetna", "plan_name": "Gravie Admin Service Aetna", "standard_charge_dollar": 293.0, "methodology": "fee schedule" }, { "payer_name": "HAP Aetna", "plan_name": "HAP Aetna", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "HCA Optum", "plan_name": "HCA Optum", "standard_charge_dollar": 150.0, "methodology": "fee schedule" }, { "payer_name": "Health Alliance", "plan_name": "Health Alliance", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp Integrated Solutions LLC", "plan_name": "HealthComp Integrated Solutions LLC", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 226.84, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Huntsman Mental Health Institute - BHN", "plan_name": "Huntsman Mental Health Institute - BHN", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Imagine 360 Administrators", "plan_name": "Imagine 360 Administrators", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Liberty Healthshare", "plan_name": "Liberty Healthshare", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Lucent Health", "plan_name": "Lucent Health", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Devoted Health Plans", "plan_name": "Magellan Devoted Health Plans", "standard_charge_dollar": 219.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Health Services", "plan_name": "Magellan Health Services", "standard_charge_dollar": 219.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Insurance", "plan_name": "Magellan Insurance", "standard_charge_dollar": 219.0, "methodology": "fee schedule" }, { "payer_name": "Medica Elect", "plan_name": "Medica Elect", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 284.55, "methodology": "fee schedule" }, { "payer_name": "Meritain Health- Aetna Choice POS", "plan_name": "Meritain Health- Aetna Choice POS", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Mines And Associates, PC", "plan_name": "Mines And Associates, PC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Motivhealth", "plan_name": "Motivhealth", "standard_charge_dollar": 157.0, "methodology": "fee schedule" }, { "payer_name": "Mountain Health Co-op", "plan_name": "Mountain Health Co-op", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "Multiplan", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Northeast HP- RMHP", "plan_name": "Northeast HP- RMHP", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Redirect Health - Multiplan", "plan_name": "Redirect Health - Multiplan", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "RMHP HMO Optum", "plan_name": "RMHP HMO Optum", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "RMHP Medicare Optum", "plan_name": "RMHP Medicare Optum", "standard_charge_dollar": 232.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Health Plans Medicaid", "plan_name": "Rocky Mountain Health Plans Medicaid", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Pace", "plan_name": "Rocky Mountain Pace", "standard_charge_dollar": 216.51, "methodology": "fee schedule" }, { "payer_name": "Rocky Mtn Pace", "plan_name": "Rocky Mtn Pace", "standard_charge_dollar": 216.51, "methodology": "fee schedule" }, { "payer_name": "Routt County Jail & Detention Center", "plan_name": "Routt County Jail & Detention Center", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Sanford Health Ins - Multiplan", "plan_name": "Sanford Health Ins - Multiplan", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Insurance", "plan_name": "Select Health Insurance", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Medicare Adv", "plan_name": "Select Health Medicare Adv", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Shelter Point", "plan_name": "Shelter Point", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Simplan Insurance", "plan_name": "Simplan Insurance", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Simplified Benefits Administrators", "plan_name": "Simplified Benefits Administrators", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "State Of Co Probation", "plan_name": "State Of Co Probation", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "Surest - United Health Care", "plan_name": "Surest - United Health Care", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 314.8, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Tufts Health Plan", "plan_name": "Tufts Health Plan", "standard_charge_dollar": 257.0, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care New Mexico", "plan_name": "United Health Care New Mexico", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Student Resources", "plan_name": "United Healthcare Student Resources", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Supplement", "plan_name": "United Healthcare Supplement", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Select Health", "plan_name": "United Select Health", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United World Life", "plan_name": "United World Life", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "UPMC Health Plan", "plan_name": "UPMC Health Plan", "standard_charge_dollar": 261.0, "methodology": "fee schedule" }, { "payer_name": "Wellfleet", "plan_name": "Wellfleet", "standard_charge_dollar": 250.0, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "minimum": 150.0, "maximum": 450.0 } ] }, { "description": "IOP CD GERO", "code_information": [ { "code": "H0015", "type": "HCPCS" }, { "code": "70000", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Allsavers", "plan_name": "Allsavers", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "American Republic Corp Ins", "plan_name": "American Republic Corp Ins", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "AMFirst", "plan_name": "AMFirst", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 226.84, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "Baylor Scott & White", "plan_name": "Baylor Scott & White", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Bright Health Management", "plan_name": "Bright Health Management", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health Strategies", "plan_name": "Carelon Behavioral Health Strategies", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon BH APWU", "plan_name": "Carelon BH APWU", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Employee Asst", "plan_name": "Carelon BH Employee Asst", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Great West", "plan_name": "Carelon BH Great West", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon Health Colorado Medicaid", "plan_name": "Carelon Health Colorado Medicaid", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Medicare Advantage", "plan_name": "Carelon Medicare Advantage", "standard_charge_dollar": 267.8, "methodology": "fee schedule" }, { "payer_name": "Carelon Northeast Health Partners Mcaid", "plan_name": "Carelon Northeast Health Partners Mcaid", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Alliance 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"standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 270.0, "methodology": "fee schedule" }, { "payer_name": "Clear Springs Health Inc", "plan_name": "Clear Springs Health Inc", "standard_charge_dollar": 231.45, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 258.0, "methodology": "fee schedule" }, { "payer_name": "Colo Community Health Alliance", "plan_name": "Colo Community Health Alliance", "standard_charge_dollar": 312.12, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 367.5, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access CHP+", "plan_name": "Colorado Access CHP+", "standard_charge_dollar": 367.5, "methodology": "fee schedule" }, { "payer_name": "ComPsych", "plan_name": "ComPsych", "standard_charge_dollar": 289.0, "methodology": "fee schedule" }, { "payer_name": "Continental Insurance - Marpai Health", "plan_name": "Continental Insurance - Marpai Health", "standard_charge_dollar": 258.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health DHHA", "plan_name": "Denver Health DHHA", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Elevate Silver", "plan_name": "Denver Health Elevate Silver", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Med Plan Cofinity", "plan_name": "Denver Health Med Plan Cofinity", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Employers Health Network", "plan_name": "Employers Health Network", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Enterprise Group Planning, Inc", "plan_name": "Enterprise Group Planning, Inc", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Federal Blue Cross", "plan_name": "Federal Blue Cross", "standard_charge_dollar": 231.75, "methodology": "fee schedule" }, { "payer_name": "First Choice Health Network", "plan_name": "First Choice Health Network", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Friday Health Plans", "plan_name": "Friday Health Plans", "standard_charge_dollar": 321.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "Gravie Admin Service Aetna", "plan_name": "Gravie Admin Service Aetna", "standard_charge_dollar": 293.0, "methodology": "fee schedule" }, { "payer_name": "HAP Aetna", "plan_name": "HAP Aetna", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "HCA Optum", "plan_name": "HCA Optum", "standard_charge_dollar": 150.0, "methodology": "fee schedule" }, { "payer_name": "Health Alliance", "plan_name": "Health Alliance", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp Integrated Solutions LLC", "plan_name": "HealthComp Integrated Solutions LLC", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 226.84, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 300.0, "methodology": "fee 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Business Benefits", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Tufts Health Plan", "plan_name": "Tufts Health Plan", "standard_charge_dollar": 257.0, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care New Mexico", "plan_name": "United Health Care New Mexico", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Student Resources", "plan_name": "United Healthcare Student Resources", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Supplement", "plan_name": "United Healthcare Supplement", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United Select Health", "plan_name": "United Select Health", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "United World Life", "plan_name": "United World Life", "standard_charge_dollar": 165.0, "methodology": "fee schedule" }, { "payer_name": "UPMC Health Plan", "plan_name": "UPMC Health Plan", "standard_charge_dollar": 261.0, "methodology": "fee schedule" }, { "payer_name": "Wellfleet", "plan_name": "Wellfleet", "standard_charge_dollar": 250.0, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "minimum": 150.0, "maximum": 450.0 } ] }, { "description": "TRI ADOL CD IOP", "code_information": [ { "code": "H0015", "type": "HCPCS" }, { "code": "70005", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 208.39, "methodology": "fee schedule" }, { "payer_name": "ASI Tricare Retired Supplement", "plan_name": "ASI Tricare Retired Supplement", "standard_charge_dollar": 172.02, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 398.0, "methodology": "fee schedule" }, { "payer_name": "Humana Tricare East", "plan_name": "Humana Tricare East", "standard_charge_dollar": 172.02, "methodology": "fee schedule" }, { "payer_name": "MBA Tricare Supplemental", "plan_name": "MBA Tricare Supplemental", "standard_charge_dollar": 172.02, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 172.02, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 172.02, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 172.02, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 172.02, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 172.02, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 172.02, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 172.02, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 398.0, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "minimum": 172.02, "maximum": 398.0 } ] }, { "description": "TRI ADULT CD IOP", "code_information": [ { "code": "H0015", "type": "HCPCS" }, { "code": "70004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 208.39, "methodology": "fee schedule" }, { "payer_name": "ASI Tricare Retired Supplement", "plan_name": "ASI Tricare Retired Supplement", "standard_charge_dollar": 172.02, "methodology": "fee schedule" }, { "payer_name": "Employers Health Network", "plan_name": "Employers Health Network", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Gravie Admin Service Aetna", "plan_name": "Gravie Admin Service Aetna", "standard_charge_dollar": 293.0, "methodology": "fee schedule" }, { "payer_name": "HAP Aetna", "plan_name": "HAP Aetna", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp 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"methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 172.02, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 172.02, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 172.02, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 172.02, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 172.02, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 172.02, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 398.0, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 250.0, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "minimum": 172.02, "maximum": 398.0 } ] }, { "description": "TRI Adult IOP CD - 2 Units", "code_information": [ { "code": "H0015", "type": "HCPCS" }, { "code": "602", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 199.0, "methodology": "fee schedule" } ], "gross_charge": 850.0, "minimum": 199.0, "maximum": 199.0 } ] }, { "description": "TRI Adult IOP CD- 3 Units", "code_information": [ { "code": "H0015", "type": "HCPCS" }, { "code": "603", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 132.67, "methodology": "fee schedule" } ], "gross_charge": 566.67, "minimum": 132.67, "maximum": 132.67 } ] }, { "description": "TRI GERO CD IOP", "code_information": [ { "code": "H0015", "type": "HCPCS" }, { "code": "70003", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 208.39, "methodology": "fee schedule" }, { "payer_name": "ASI Tricare Retired Supplement", "plan_name": "ASI Tricare Retired Supplement", "standard_charge_dollar": 172.02, "methodology": "fee schedule" }, { "payer_name": "Employers Health Network", "plan_name": "Employers Health Network", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Gravie Admin Service Aetna", "plan_name": "Gravie Admin Service Aetna", "standard_charge_dollar": 293.0, "methodology": "fee schedule" }, { "payer_name": "HAP Aetna", "plan_name": "HAP Aetna", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp Integrated Solutions LLC", "plan_name": "HealthComp Integrated Solutions LLC", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 398.0, "methodology": "fee schedule" }, { "payer_name": "Humana Tricare East", "plan_name": "Humana Tricare East", "standard_charge_dollar": 172.02, "methodology": "fee schedule" }, { "payer_name": "MBA Tricare Supplemental", "plan_name": "MBA Tricare Supplemental", "standard_charge_dollar": 172.02, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 284.55, "methodology": "fee schedule" }, { "payer_name": "Meritain Health- Aetna Choice POS", "plan_name": "Meritain Health- Aetna Choice POS", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 172.02, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 172.02, "methodology": "fee schedule" }, { "payer_name": 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"fee schedule" } ], "gross_charge": 1700.0, "minimum": 172.02, "maximum": 398.0 } ] }, { "description": "Tri Gero IOP - 2 units", "code_information": [ { "code": "H0015", "type": "HCPCS" }, { "code": "6452", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 85.36, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "minimum": 85.36, "maximum": 85.36 } ] }, { "description": "Tri Gero IOP - 3 unit", "code_information": [ { "code": "H0015", "type": "HCPCS" }, { "code": "6453", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 56.91, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "minimum": 56.91, "maximum": 56.91 } ] }, { "description": 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Senior Supplemental Ins", "standard_charge_dollar": 436.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Allied Benefits Systems", "plan_name": "Allied Benefits Systems", "standard_charge_dollar": 572.0, "methodology": "fee schedule" }, { "payer_name": "Allied Trades Assistance Program", "plan_name": "Allied Trades Assistance Program", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Allsavers", "plan_name": "Allsavers", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "AMFirst", "plan_name": "AMFirst", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 562.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Arapahoe County Dept Of Human Services", "plan_name": "Arapahoe County Dept Of Human Services", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "ASR Health", "plan_name": "ASR Health", "standard_charge_dollar": 431.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 345.0, 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"plan_name": "Cigna", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Alliance Health And Life", "plan_name": "Cigna Alliance Health And Life", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Health Spring Medicare Advantage", "plan_name": "Cigna Health Spring Medicare Advantage", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Supplemental", "plan_name": "Cigna Supplemental", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Cigna True Choice Medicare PPO", "plan_name": "Cigna True Choice Medicare PPO", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Zenith Administrators", "plan_name": "Cigna Zenith Administrators", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 436.0, "methodology": "fee schedule" }, { "payer_name": "Colo Community Health Alliance", "plan_name": "Colo Community Health Alliance", "standard_charge_dollar": 359.04, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 441.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access CHP+", "plan_name": "Colorado Access CHP+", "standard_charge_dollar": 441.0, "methodology": "fee schedule" }, { "payer_name": "ComPsych", "plan_name": "ComPsych", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Continental Insurance - Marpai Health", "plan_name": "Continental Insurance - Marpai Health", "standard_charge_dollar": 463.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 435.6, "methodology": "fee schedule" }, { "payer_name": "Dean Health Plans", "plan_name": "Dean Health Plans", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health DHHA", "plan_name": "Denver Health DHHA", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Elevate Silver", "plan_name": "Denver Health Elevate Silver", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Med Plan Cofinity", "plan_name": "Denver Health Med Plan Cofinity", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 449.0, "methodology": "fee schedule" }, { "payer_name": "Employers Health Network", "plan_name": "Employers Health Network", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "Enterprise Group Planning, Inc", "plan_name": "Enterprise Group Planning, Inc", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Equitable Plan Services", "plan_name": "Equitable Plan Services", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Federal Blue Cross", "plan_name": "Federal Blue Cross", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "First Choice Health Network", "plan_name": "First Choice Health Network", "standard_charge_dollar": 449.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Friday Health Plans", "plan_name": "Friday Health Plans", "standard_charge_dollar": 523.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Gravie Admin Service Aetna", "plan_name": "Gravie Admin Service Aetna", "standard_charge_dollar": 526.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "HAP Aetna", "plan_name": "HAP Aetna", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "HCA Optum", "plan_name": "HCA Optum", "standard_charge_dollar": 293.0, "methodology": "fee schedule" }, { "payer_name": "Health Alliance", "plan_name": "Health Alliance", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Health Management Concepts", "plan_name": "Health Management Concepts", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Commercial Claims", "plan_name": "Health Net Commercial Claims", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp Integrated Solutions LLC", "plan_name": "HealthComp Integrated Solutions LLC", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 463.0, "methodology": "fee schedule" }, { "payer_name": "Hemet Community Medical Group", "plan_name": "Hemet Community Medical Group", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 60.57, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Huntsman Mental Health Institute - BHN", "plan_name": "Huntsman Mental Health Institute - BHN", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "HWBS Claims", "plan_name": "HWBS Claims", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Imagine 360 Administrators", "plan_name": "Imagine 360 Administrators", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Denver", "plan_name": "Kaiser Permanente Denver", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Northern", "plan_name": "Kaiser Permanente Northern", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Senior Advantage HMO", "plan_name": "Kaiser Permanente Senior Advantage HMO", "standard_charge_dollar": 393.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente/KPIC", "plan_name": "Kaiser Permanente/KPIC", "standard_charge_dollar": 167.83, "methodology": "fee schedule" }, { "payer_name": "Liberty Healthshare", "plan_name": "Liberty Healthshare", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Life Shield STM - Ins TPA", "plan_name": "Life Shield STM - Ins TPA", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "LINECO Mental Health & Substance Abuse", "plan_name": "LINECO Mental Health & Substance Abuse", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "Lucent Health", "plan_name": "Lucent Health", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Devoted Health Plans", "plan_name": "Magellan Devoted Health Plans", "standard_charge_dollar": 455.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Health Services", "plan_name": "Magellan Health Services", "standard_charge_dollar": 455.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Insurance", "plan_name": "Magellan Insurance", "standard_charge_dollar": 455.0, "methodology": "fee schedule" }, { "payer_name": "Mailhandlers", "plan_name": "Mailhandlers", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Managed Care Insurance - MBR Claims", "plan_name": "Managed Care Insurance - MBR Claims", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Medica Elect", "plan_name": "Medica Elect", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health- Aetna Choice POS", "plan_name": "Meritain Health- Aetna Choice POS", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "MERP Administrative Services", "plan_name": "MERP Administrative Services", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "MHNET", 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"plan_name": "Multiplan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "New Mexico Medicaid", "plan_name": "New Mexico Medicaid", "standard_charge_dollar": 530.0, "methodology": "fee schedule" }, { "payer_name": "Northeast HP- RMHP", "plan_name": "Northeast HP- RMHP", "standard_charge_dollar": 373.5, "methodology": "fee schedule" }, { "payer_name": "OPTUM EMPIRE HEALTH PLAN", "plan_name": "OPTUM EMPIRE HEALTH PLAN", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Optum Health Behavioral Solutions", "plan_name": "Optum Health Behavioral Solutions", "standard_charge_dollar": 260.0, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Pacificare Behavioral Health", "plan_name": "Pacificare Behavioral Health", "standard_charge_dollar": 273.0, "methodology": "fee schedule" }, { "payer_name": "ParkCare Plus", "plan_name": "ParkCare Plus", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Physicians Mutual Insurance Company", "plan_name": "Physicians Mutual Insurance Company", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "Preferred One Administrative Services", "plan_name": "Preferred One Administrative Services", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Priority Health Insurance", "plan_name": "Priority Health Insurance", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Provider Network Of America", "plan_name": "Provider Network Of America", "standard_charge_dollar": 324.77, "methodology": "fee schedule" }, { "payer_name": "Reserve Officers Assoc Insurance", "plan_name": "Reserve Officers Assoc Insurance", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "RMHP Commercial Optun", "plan_name": "RMHP Commercial Optun", "standard_charge_dollar": 710.7, "methodology": "fee schedule" }, { "payer_name": "RMHP HMO Optum", "plan_name": "RMHP HMO Optum", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "RMHP Medicare Optum", "plan_name": "RMHP Medicare Optum", "standard_charge_dollar": 235.0, "methodology": "fee schedule" }, { "payer_name": "RMSCO, Inc", "plan_name": "RMSCO, Inc", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Health Plans Medicaid", "plan_name": "Rocky Mountain Health Plans Medicaid", "standard_charge_dollar": 373.5, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain-Life Strategies", "plan_name": "Rocky Mountain-Life Strategies", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Routt County Jail & Detention Center", "plan_name": "Routt County Jail & Detention Center", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Sanford Health Ins - Multiplan", "plan_name": "Sanford Health Ins - Multiplan", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "SECURE HORIZONS", "plan_name": "SECURE HORIZONS", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons Direct", "plan_name": "Secure Horizons Direct", "standard_charge_dollar": 273.0, "methodology": "fee schedule" }, { "payer_name": "Select Benefits Administrators", "plan_name": "Select Benefits Administrators", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Insurance", "plan_name": "Select Health Insurance", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Medicare Adv", "plan_name": "Select Health Medicare Adv", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 273.0, "methodology": "fee schedule" }, { "payer_name": "Selman Co", "plan_name": "Selman Co", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Sheet Metal Workers", "plan_name": "Sheet Metal Workers", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "Shelter Point", "plan_name": "Shelter Point", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Simplan Insurance", "plan_name": "Simplan Insurance", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Simplified Benefits Administrators", "plan_name": "Simplified Benefits Administrators", "standard_charge_dollar": 750.0, "methodology": "fee schedule" }, { "payer_name": "Starmark Insurance", "plan_name": "Starmark Insurance", "standard_charge_dollar": 436.0, "methodology": "fee schedule" }, { "payer_name": "State Of Co Probation", "plan_name": "State Of Co Probation", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Surest - United Health Care", "plan_name": "Surest - United Health Care", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "TLC Benefits Solution Inc.", "plan_name": "TLC Benefits Solution Inc.", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Travelers Insurance", "plan_name": "Travelers Insurance", "standard_charge_dollar": 224.27, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 436.0, "methodology": "fee schedule" }, { "payer_name": "Tufts Health Plan", "plan_name": "Tufts Health Plan", "standard_charge_dollar": 479.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 273.0, "methodology": "fee schedule" }, { "payer_name": "UMR/CEBT-PM085516", "plan_name": "UMR/CEBT-PM085516", "standard_charge_dollar": 260.0, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care New Mexico", "plan_name": "United Health Care New Mexico", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Student Resources", "plan_name": "United Healthcare Student Resources", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Supplement", "plan_name": "United Healthcare Supplement", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United Select Health", "plan_name": "United Select Health", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United World Life", "plan_name": "United World Life", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "UPMC Health Plan", "plan_name": "UPMC Health Plan", "standard_charge_dollar": 486.0, "methodology": "fee schedule" }, { "payer_name": "WEBB TPA", "plan_name": "WEBB TPA", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Wellfleet", "plan_name": "Wellfleet", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Winhealth", "plan_name": "Winhealth", "standard_charge_dollar": 350.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 60.57, "maximum": 750.0 } ] }, { "description": "Gero Psych PHP 6 hrs", "code_information": [ { "code": "H0035", "type": "HCPCS" }, { "code": "6250", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 436.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 436.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 463.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 436.0, "methodology": "fee schedule" }, { "payer_name": "Allsavers", "plan_name": "Allsavers", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "American Republic Corp Ins", "plan_name": "American Republic Corp Ins", "standard_charge_dollar": 449.0, "methodology": "fee schedule" }, { "payer_name": "AMFirst", "plan_name": "AMFirst", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 562.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "ASR Health", "plan_name": "ASR Health", "standard_charge_dollar": 431.0, "methodology": "fee schedule" }, { "payer_name": "Baylor Scott & White", "plan_name": "Baylor Scott & White", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "BCBS HMO Colorado", "plan_name": "BCBS HMO Colorado", "standard_charge_dollar": 546.0, "methodology": "fee schedule" }, { "payer_name": "Ben-E-Lect", "plan_name": "Ben-E-Lect", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Blue Cross Blue Shield", "plan_name": "Blue Cross Blue Shield", "standard_charge_dollar": 546.0, "methodology": "fee schedule" }, { "payer_name": "Bright Health Management", "plan_name": "Bright Health Management", "standard_charge_dollar": 637.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 393.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 393.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Health Colorado Medicaid", "plan_name": "Carelon Health 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schedule" }, { "payer_name": "Cigna Supplemental", "plan_name": "Cigna Supplemental", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Cigna True Choice Medicare PPO", "plan_name": "Cigna True Choice Medicare PPO", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Zenith Administrators", "plan_name": "Cigna Zenith Administrators", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Colo Community Health Alliance", "plan_name": "Colo Community Health Alliance", "standard_charge_dollar": 359.04, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 441.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access CHP+", "plan_name": "Colorado Access CHP+", "standard_charge_dollar": 441.0, "methodology": "fee schedule" }, { "payer_name": "ComPsych", "plan_name": "ComPsych", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Continental Insurance - Marpai Health", "plan_name": "Continental Insurance - Marpai Health", "standard_charge_dollar": 463.0, "methodology": "fee schedule" }, { "payer_name": "Coventry", "plan_name": "Coventry", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health DHHA", "plan_name": "Denver Health DHHA", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Elevate Silver", "plan_name": "Denver Health Elevate Silver", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Med Plan Cofinity", "plan_name": "Denver Health Med Plan Cofinity", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Enterprise Group Planning, Inc", "plan_name": "Enterprise Group Planning, Inc", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Federal Blue Cross", "plan_name": "Federal Blue Cross", "standard_charge_dollar": 587.86, "methodology": "fee schedule" }, { "payer_name": "First Choice Health Network", "plan_name": "First Choice Health Network", "standard_charge_dollar": 449.0, "methodology": "fee schedule" }, { "payer_name": "Friday Health Plans", "plan_name": "Friday Health Plans", "standard_charge_dollar": 523.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "HCA Optum", "plan_name": "HCA Optum", "standard_charge_dollar": 293.0, "methodology": "fee schedule" }, { "payer_name": "Health Alliance", "plan_name": "Health Alliance", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 463.0, "methodology": "fee schedule" }, { "payer_name": "Houston Casualty Co", "plan_name": "Houston Casualty Co", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Huntsman Mental Health Institute - BHN", "plan_name": "Huntsman Mental Health Institute - BHN", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Imagine 360 Administrators", "plan_name": "Imagine 360 Administrators", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Liberty Healthshare", "plan_name": "Liberty Healthshare", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Devoted Health Plans", "plan_name": "Magellan Devoted Health Plans", "standard_charge_dollar": 455.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Health Services", "plan_name": "Magellan Health Services", "standard_charge_dollar": 455.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Insurance", "plan_name": "Magellan Insurance", "standard_charge_dollar": 455.0, "methodology": "fee schedule" }, { "payer_name": "Mailhandlers", "plan_name": "Mailhandlers", "standard_charge_dollar": 260.0, "methodology": "fee schedule" }, { "payer_name": "Mayo Health Solutions", "plan_name": "Mayo Health Solutions", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Medica Elect", "plan_name": "Medica Elect", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health- Aetna Choice POS", "plan_name": "Meritain Health- Aetna Choice POS", "standard_charge_dollar": 436.0, "methodology": "fee schedule" }, { "payer_name": "Modern Assistance Program", "plan_name": "Modern Assistance Program", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Of Texas", "plan_name": "Molina Healthcare Of Texas", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Motivhealth", "plan_name": "Motivhealth", "standard_charge_dollar": 307.65, "methodology": "fee schedule" }, { "payer_name": "Mountain Health Co-op", "plan_name": "Mountain Health Co-op", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "New Mexico Medicaid", "plan_name": "New Mexico Medicaid", "standard_charge_dollar": 530.0, "methodology": "fee schedule" }, { "payer_name": "Northeast HP- RMHP", "plan_name": "Northeast HP- RMHP", "standard_charge_dollar": 373.5, "methodology": "fee schedule" }, { "payer_name": "Optum Health Behavioral Solutions", "plan_name": "Optum Health Behavioral Solutions", "standard_charge_dollar": 260.0, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Pacificare Behavioral Health", "plan_name": "Pacificare Behavioral Health", "standard_charge_dollar": 273.0, "methodology": "fee schedule" }, { "payer_name": "ParkCare Plus", "plan_name": "ParkCare Plus", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Provider Network Of America", "plan_name": "Provider Network Of America", "standard_charge_dollar": 324.77, "methodology": "fee schedule" }, { "payer_name": "RMHP Medicare Optum", "plan_name": "RMHP Medicare Optum", "standard_charge_dollar": 235.0, "methodology": "fee schedule" }, { "payer_name": "Routt County Jail & Detention Center", "plan_name": "Routt County Jail & Detention Center", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons Direct", "plan_name": "Secure Horizons Direct", "standard_charge_dollar": 273.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Insurance", "plan_name": "Select Health Insurance", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Medicare Adv", "plan_name": "Select Health Medicare Adv", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 273.0, "methodology": "fee schedule" }, { "payer_name": "Shelter Point", "plan_name": "Shelter Point", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Simplan Insurance", "plan_name": "Simplan Insurance", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Simplified Benefits Administrators", "plan_name": "Simplified Benefits Administrators", "standard_charge_dollar": 750.0, "methodology": "fee schedule" }, { "payer_name": "Starmark Insurance", "plan_name": "Starmark Insurance", "standard_charge_dollar": 436.0, "methodology": "fee schedule" }, { "payer_name": "State Of Co Probation", "plan_name": "State Of Co Probation", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Surest - United Health Care", "plan_name": "Surest - United Health Care", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Trans America Ins", "plan_name": "Trans America Ins", "standard_charge_dollar": 220.0, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 436.0, "methodology": "fee schedule" }, { "payer_name": "Tufts Health Plan", "plan_name": "Tufts Health Plan", "standard_charge_dollar": 479.0, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care New Mexico", "plan_name": "United Health Care New Mexico", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Student Resources", "plan_name": "United Healthcare Student Resources", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Supplement", "plan_name": "United Healthcare Supplement", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United Select Health", "plan_name": "United Select Health", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United World Life", "plan_name": "United World Life", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "UPMC Health Plan", "plan_name": "UPMC Health Plan", "standard_charge_dollar": 486.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 220.0, "maximum": 750.0 } ] }, { "description": "PHP Adol/Child Psych 6hr", "code_information": [ { "code": "H0035", "type": "HCPCS" }, { "code": "200", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 436.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 435.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 435.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Allied Benefits Systems", "plan_name": "Allied Benefits Systems", "standard_charge_dollar": 572.0, "methodology": "fee schedule" }, { "payer_name": "Allied Trades Assistance Program", "plan_name": "Allied Trades Assistance Program", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Allsavers", "plan_name": "Allsavers", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "AMFirst", "plan_name": "AMFirst", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 562.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "ASR Health", "plan_name": "ASR Health", "standard_charge_dollar": 431.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Baylor Scott & White", "plan_name": "Baylor Scott & White", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "BCBS HMO Colorado", "plan_name": "BCBS HMO Colorado", "standard_charge_dollar": 546.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Bind Benefits, Inc", "plan_name": "Bind Benefits, Inc", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Blue Cross Blue Shield", "plan_name": "Blue Cross Blue Shield", "standard_charge_dollar": 546.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Bright Health Management", "plan_name": "Bright Health Management", "standard_charge_dollar": 637.0, "methodology": "fee schedule" }, { "payer_name": "Bright Health Medicare Advantage", "plan_name": "Bright Health Medicare Advantage", "standard_charge_dollar": 637.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 420.98, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health Strategies", "plan_name": "Carelon Behavioral Health Strategies", "standard_charge_dollar": 420.98, "methodology": "fee schedule" }, { "payer_name": "Carelon BH APWU", "plan_name": "Carelon BH APWU", "standard_charge_dollar": 420.98, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Employee Asst", "plan_name": "Carelon BH Employee Asst", "standard_charge_dollar": 420.98, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Great West", "plan_name": "Carelon BH Great West", "standard_charge_dollar": 420.98, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 420.98, "methodology": "fee schedule" }, { "payer_name": "Carelon Health Colorado Medicaid", "plan_name": "Carelon Health Colorado Medicaid", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Medicare Advantage", "plan_name": "Carelon Medicare Advantage", "standard_charge_dollar": 420.98, "methodology": "fee schedule" }, { "payer_name": "Carelon Northeast Health Partners Mcaid", "plan_name": "Carelon Northeast Health Partners Mcaid", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 278.0, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Alliance Health And Life", "plan_name": "Cigna Alliance Health And Life", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Health Spring Medicare Advantage", "plan_name": "Cigna Health Spring Medicare Advantage", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Supplemental", "plan_name": "Cigna Supplemental", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Cigna True Choice Medicare PPO", "plan_name": "Cigna True Choice Medicare PPO", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Zenith Administrators", "plan_name": "Cigna Zenith Administrators", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 503.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 436.0, "methodology": "fee schedule" }, { "payer_name": "Colo Community Health Alliance", "plan_name": "Colo Community Health Alliance", "standard_charge_dollar": 359.04, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 441.0, "methodology": "fee schedule" }, { 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"standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health DHHA", "plan_name": "Denver Health DHHA", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Elevate Silver", "plan_name": "Denver Health Elevate Silver", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Med Plan Cofinity", "plan_name": "Denver Health Med Plan Cofinity", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 449.0, "methodology": "fee schedule" }, { "payer_name": "Enterprise Group Planning, Inc", "plan_name": "Enterprise Group Planning, Inc", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Equitable Plan Services", "plan_name": "Equitable Plan Services", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Federal Blue Cross", "plan_name": "Federal Blue Cross", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "First Choice Health Network", "plan_name": "First Choice Health Network", "standard_charge_dollar": 449.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Friday Health Plans", "plan_name": "Friday Health Plans", "standard_charge_dollar": 523.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Gravie Admin Service Aetna", "plan_name": "Gravie Admin Service Aetna", "standard_charge_dollar": 526.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "HAP Aetna", "plan_name": "HAP Aetna", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "HCA Optum", "plan_name": "HCA Optum", "standard_charge_dollar": 293.0, "methodology": "fee schedule" }, { "payer_name": "Health Alliance", "plan_name": "Health Alliance", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Health Management Concepts", "plan_name": "Health Management Concepts", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Health Net Commercial Claims", "plan_name": "Health Net Commercial Claims", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp Integrated Solutions LLC", "plan_name": "HealthComp Integrated Solutions LLC", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 463.0, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Huntsman Mental Health Institute - BHN", "plan_name": "Huntsman Mental Health Institute - BHN", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "HWBS Claims", "plan_name": "HWBS Claims", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Imagine 360 Administrators", "plan_name": "Imagine 360 Administrators", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Of Colorado", "plan_name": "Kaiser Of Colorado", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Perm CHP", "plan_name": "Kaiser Perm CHP", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente", "plan_name": "Kaiser Permanente", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Denver", "plan_name": "Kaiser Permanente Denver", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Northern", "plan_name": "Kaiser Permanente Northern", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Liberty Healthshare", "plan_name": "Liberty Healthshare", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Life Shield STM - Ins TPA", "plan_name": "Life Shield STM - Ins TPA", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "LINECO Mental Health & Substance Abuse", "plan_name": "LINECO Mental Health & Substance Abuse", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "Lucent Health", "plan_name": "Lucent Health", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Devoted Health Plans", "plan_name": "Magellan Devoted Health Plans", "standard_charge_dollar": 455.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Health Services", "plan_name": "Magellan Health Services", "standard_charge_dollar": 455.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Insurance", "plan_name": "Magellan Insurance", "standard_charge_dollar": 455.0, "methodology": "fee schedule" }, { "payer_name": "Mailhandlers", "plan_name": "Mailhandlers", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Managed Care Insurance - MBR Claims", "plan_name": "Managed Care Insurance - MBR Claims", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Network Group", "plan_name": "Managed Health Network Group", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Medica Elect", "plan_name": "Medica Elect", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health- Aetna Choice POS", "plan_name": "Meritain Health- Aetna Choice POS", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "MERP Administrative Services", "plan_name": "MERP Administrative Services", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "MHNET", "plan_name": "MHNET", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "Mines And Associates, PC", "plan_name": "Mines And Associates, PC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Modern Assistance Program", "plan_name": "Modern Assistance Program", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Of Texas", "plan_name": "Molina Healthcare Of Texas", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Motivhealth", "plan_name": "Motivhealth", "standard_charge_dollar": 307.65, "methodology": "fee schedule" }, { "payer_name": "Mountain Health Co-op", "plan_name": "Mountain Health Co-op", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "Multiplan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "NALC Health Benefit Plan", "plan_name": "NALC Health Benefit Plan", "standard_charge_dollar": 486.0, "methodology": "fee schedule" }, { "payer_name": "Nationwide Life", "plan_name": "Nationwide Life", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Neighborhood Health Plan", "plan_name": "Neighborhood Health Plan", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "New Mexico Medicaid", "plan_name": "New Mexico Medicaid", "standard_charge_dollar": 530.0, "methodology": "fee schedule" }, { "payer_name": "Nikola Tesia Alternative High School", "plan_name": "Nikola Tesia Alternative High School", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Northeast HP- RMHP", "plan_name": "Northeast HP- RMHP", "standard_charge_dollar": 373.5, "methodology": "fee schedule" }, { "payer_name": "OPTUM EMPIRE HEALTH PLAN", "plan_name": "OPTUM EMPIRE HEALTH PLAN", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Optum Health Behavioral Solutions", "plan_name": "Optum Health Behavioral Solutions", "standard_charge_dollar": 260.0, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "ParkCare Plus", "plan_name": "ParkCare Plus", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Physicians Mutual Insurance Company", "plan_name": "Physicians Mutual Insurance Company", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "Preferred One Administrative Services", "plan_name": "Preferred One Administrative Services", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Provider Network Of America", "plan_name": "Provider Network Of America", "standard_charge_dollar": 324.77, "methodology": "fee schedule" }, { "payer_name": "Reserve Officers Assoc Insurance", "plan_name": "Reserve Officers Assoc Insurance", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "RMHP HMO Optum", "plan_name": "RMHP HMO Optum", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "RMSCO, Inc", "plan_name": "RMSCO, Inc", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Health Plans Medicaid", "plan_name": "Rocky Mountain Health Plans Medicaid", "standard_charge_dollar": 373.5, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Human Services", "plan_name": "Rocky Mountain Human Services", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain-Life Strategies", "plan_name": "Rocky Mountain-Life Strategies", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Routt County Jail & Detention Center", "plan_name": "Routt County Jail & Detention Center", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Sanford Health Ins - Multiplan", "plan_name": "Sanford Health Ins - Multiplan", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Select Benefits Administrators", "plan_name": "Select Benefits Administrators", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Insurance", "plan_name": "Select Health Insurance", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Medicare Adv", "plan_name": "Select Health Medicare Adv", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 273.0, "methodology": "fee schedule" }, { "payer_name": "Selman Co", "plan_name": "Selman Co", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Sheet Metal Workers", "plan_name": "Sheet Metal Workers", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "Shelter Point", "plan_name": "Shelter Point", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Simplan Insurance", "plan_name": "Simplan Insurance", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Simplified Benefits Administrators", "plan_name": "Simplified Benefits Administrators", "standard_charge_dollar": 750.0, "methodology": "fee schedule" }, { "payer_name": "Standard Life And Accident Insurance", "plan_name": "Standard Life And Accident Insurance", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Starmark Insurance", "plan_name": "Starmark Insurance", "standard_charge_dollar": 436.0, "methodology": "fee schedule" }, { "payer_name": "State Of Co Probation", "plan_name": "State Of Co Probation", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Surest - United Health Care", "plan_name": "Surest - United Health Care", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "TLC Benefits Solution Inc.", "plan_name": "TLC Benefits Solution Inc.", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Travelers Insurance", "plan_name": "Travelers Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 436.0, "methodology": "fee schedule" }, { "payer_name": "Tufts Health Plan", "plan_name": "Tufts Health Plan", "standard_charge_dollar": 479.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 260.0, "methodology": "fee schedule" }, { "payer_name": "UMR/CEBT-PM085516", "plan_name": "UMR/CEBT-PM085516", "standard_charge_dollar": 260.0, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care New Mexico", "plan_name": "United Health Care New Mexico", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Student Resources", "plan_name": "United Healthcare Student Resources", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Supplement", "plan_name": "United Healthcare Supplement", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United Select Health", "plan_name": "United Select Health", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "United World Life", "plan_name": "United World Life", "standard_charge_dollar": 323.0, "methodology": "fee schedule" }, { "payer_name": "UPMC Health Plan", "plan_name": "UPMC Health Plan", "standard_charge_dollar": 486.0, "methodology": "fee schedule" }, { "payer_name": "Wellfleet", "plan_name": "Wellfleet", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Winhealth", "plan_name": "Winhealth", "standard_charge_dollar": 350.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 188.69, "maximum": 750.0 } ] }, { "description": "PHP CD ADOL", "code_information": [ { "code": "H0035", "type": "HCPCS" }, { "code": "70013", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "American Republic Corp Ins", "plan_name": "American Republic Corp Ins", "standard_charge_dollar": 449.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 562.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health Strategies", "plan_name": "Carelon Behavioral Health Strategies", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH APWU", "plan_name": "Carelon BH APWU", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Employee Asst", "plan_name": "Carelon BH Employee Asst", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Great West", "plan_name": "Carelon BH Great West", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 393.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Health Colorado Medicaid", "plan_name": "Carelon Health Colorado Medicaid", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Northeast Health Partners Mcaid", "plan_name": "Carelon Northeast Health Partners Mcaid", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 463.0, "methodology": "fee schedule" }, { "payer_name": "ComPsych", "plan_name": "ComPsych", "standard_charge_dollar": 521.0, "methodology": "fee schedule" }, { "payer_name": "Employers Health Network", "plan_name": "Employers Health Network", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "First Choice Health Network", "plan_name": "First Choice Health Network", "standard_charge_dollar": 449.0, "methodology": "fee schedule" }, { "payer_name": "Gravie Admin Service Aetna", "plan_name": "Gravie Admin Service Aetna", "standard_charge_dollar": 526.0, "methodology": "fee schedule" }, { "payer_name": "HAP Aetna", "plan_name": "HAP Aetna", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp Integrated Solutions LLC", "plan_name": "HealthComp Integrated Solutions LLC", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "Huntsman Mental Health Institute - BHN", "plan_name": "Huntsman Mental Health Institute - BHN", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Lucent Health", "plan_name": "Lucent Health", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 510.3, "methodology": "fee schedule" }, { "payer_name": "Meritain Health- Aetna Choice POS", "plan_name": "Meritain Health- Aetna Choice POS", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "Mountain Health Co-op", "plan_name": "Mountain Health Co-op", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "Multiplan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Northeast HP- RMHP", "plan_name": "Northeast HP- RMHP", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Redirect Health - Multiplan", "plan_name": "Redirect Health - Multiplan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "RMHP HMO Optum", "plan_name": "RMHP HMO Optum", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Sanford Health Ins - Multiplan", "plan_name": "Sanford Health Ins - Multiplan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Simplified Benefits Administrators", "plan_name": "Simplified Benefits Administrators", "standard_charge_dollar": 750.0, "methodology": "fee schedule" }, { "payer_name": "State Of Co Probation", "plan_name": "State Of Co Probation", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 449.0, "methodology": "fee schedule" }, { "payer_name": "Wellfleet", "plan_name": "Wellfleet", "standard_charge_dollar": 550.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 359.0, "maximum": 750.0 } ] }, { "description": "PHP CD ADULT", "code_information": [ { "code": "H0035", "type": "HCPCS" }, { "code": "70012", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "American Republic Corp Ins", "plan_name": "American Republic Corp Ins", "standard_charge_dollar": 449.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 562.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", 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"standard_charge_dollar": 463.0, "methodology": "fee schedule" }, { "payer_name": "ComPsych", "plan_name": "ComPsych", "standard_charge_dollar": 521.0, "methodology": "fee schedule" }, { "payer_name": "Employers Health Network", "plan_name": "Employers Health Network", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "First Choice Health Network", "plan_name": "First Choice Health Network", "standard_charge_dollar": 449.0, "methodology": "fee schedule" }, { "payer_name": "Gravie Admin Service Aetna", "plan_name": "Gravie Admin Service Aetna", "standard_charge_dollar": 526.0, "methodology": "fee schedule" }, { "payer_name": "HAP Aetna", "plan_name": "HAP Aetna", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp Integrated Solutions LLC", "plan_name": "HealthComp Integrated Solutions LLC", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "Huntsman Mental Health Institute - BHN", "plan_name": "Huntsman Mental Health Institute - BHN", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Lucent Health", "plan_name": "Lucent Health", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 510.3, "methodology": "fee schedule" }, { "payer_name": "Meritain Health- Aetna Choice POS", "plan_name": "Meritain Health- Aetna Choice POS", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "Mines And Associates, PC", "plan_name": "Mines And Associates, PC", "standard_charge_dollar": 650.0, "methodology": "fee schedule" }, { "payer_name": "Mountain Health Co-op", "plan_name": "Mountain Health Co-op", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "Multiplan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Northeast 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"methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 449.0, "methodology": "fee schedule" }, { "payer_name": "Wellfleet", "plan_name": "Wellfleet", "standard_charge_dollar": 550.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 235.0, "maximum": 750.0 } ] }, { "description": "PHP CD GERO", "code_information": [ { "code": "H0035", "type": "HCPCS" }, { "code": "70011", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "American Republic Corp Ins", "plan_name": "American Republic Corp Ins", "standard_charge_dollar": 449.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 562.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health Strategies", "plan_name": "Carelon Behavioral Health Strategies", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH APWU", "plan_name": "Carelon BH APWU", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Employee Asst", "plan_name": "Carelon BH Employee Asst", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Great West", "plan_name": "Carelon BH Great West", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 393.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Health Colorado Medicaid", "plan_name": "Carelon Health Colorado Medicaid", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Northeast Health Partners Mcaid", "plan_name": "Carelon Northeast Health Partners Mcaid", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 463.0, "methodology": "fee schedule" }, { "payer_name": "ComPsych", "plan_name": "ComPsych", "standard_charge_dollar": 521.0, "methodology": "fee schedule" }, { "payer_name": "Employers Health Network", "plan_name": "Employers Health Network", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "First Choice Health Network", "plan_name": "First Choice Health Network", "standard_charge_dollar": 449.0, "methodology": "fee schedule" }, { "payer_name": "Gravie Admin Service Aetna", "plan_name": "Gravie Admin Service Aetna", "standard_charge_dollar": 526.0, "methodology": "fee schedule" }, { "payer_name": "HAP Aetna", "plan_name": "HAP Aetna", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp Integrated Solutions LLC", "plan_name": "HealthComp Integrated Solutions LLC", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "Huntsman Mental Health Institute - BHN", "plan_name": "Huntsman Mental Health Institute - BHN", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Lucent Health", "plan_name": "Lucent Health", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 510.3, "methodology": "fee schedule" }, { "payer_name": "Meritain Health- Aetna Choice POS", "plan_name": "Meritain Health- Aetna Choice POS", "standard_charge_dollar": 542.0, "methodology": "fee schedule" }, { "payer_name": "Mines And Associates, PC", "plan_name": "Mines And Associates, PC", "standard_charge_dollar": 650.0, "methodology": "fee schedule" }, { "payer_name": "Mountain Health Co-op", "plan_name": "Mountain Health Co-op", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Multiplan", "plan_name": "Multiplan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Northeast HP- RMHP", "plan_name": "Northeast HP- RMHP", "standard_charge_dollar": 373.5, "methodology": "fee schedule" }, { "payer_name": "Redirect Health - Multiplan", "plan_name": "Redirect Health - Multiplan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "RMHP HMO Optum", "plan_name": "RMHP HMO Optum", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "RMHP Medicare Optum", "plan_name": "RMHP Medicare Optum", "standard_charge_dollar": 235.0, "methodology": "fee schedule" }, { "payer_name": "Sanford Health Ins - Multiplan", "plan_name": "Sanford Health Ins - Multiplan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Simplified Benefits Administrators", "plan_name": "Simplified Benefits Administrators", "standard_charge_dollar": 750.0, "methodology": "fee schedule" }, { "payer_name": "State Of Co Probation", "plan_name": "State Of Co Probation", "standard_charge_dollar": 578.86, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 449.0, "methodology": "fee schedule" }, { "payer_name": "Wellfleet", "plan_name": "Wellfleet", "standard_charge_dollar": 550.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 235.0, "maximum": 750.0 } ] }, { "description": "PHP Daily Adult", "code_information": [ { "code": "H0035", "type": "HCPCS" }, { "code": "5200", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Bankers Fidelity", "plan_name": "Bankers Fidelity", "standard_charge_dollar": 400.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 400.0, "maximum": 400.0 } ] }, { "description": "PHP Daily Gero", "code_information": [ { "code": "H0035", "type": "HCPCS" }, { "code": "5220", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Bankers Fidelity", "plan_name": "Bankers Fidelity", "standard_charge_dollar": 400.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 400.0, "maximum": 400.0 } ] }, { "description": "MCR ADULT CD IOP - 3 UNITS", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "70009", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 302.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 75.62, "methodology": "fee schedule" }, { "payer_name": "Clear Springs Health Inc", "plan_name": "Clear Springs Health Inc", "standard_charge_dollar": 77.15, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 314.8, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Senior Advantage HMO", "plan_name": "Kaiser Permanente Senior Advantage HMO", "standard_charge_dollar": 69.47, "methodology": "fee schedule" }, { "payer_name": "Magellan Devoted Health Plans", "plan_name": "Magellan Devoted Health Plans", "standard_charge_dollar": 73.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 75.62, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 77.15, "methodology": "fee schedule" } ], "gross_charge": 566.67, "minimum": 69.47, "maximum": 314.8 } ] }, { "description": "MCR ADULT IOP CD - 2 UNITS", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "70008", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 255.15, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 113.42, "methodology": "fee schedule" }, { "payer_name": "Bright Health Medicare Advantage", "plan_name": "Bright Health Medicare Advantage", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "Clear Springs Health Inc", "plan_name": "Clear Springs Health Inc", "standard_charge_dollar": 115.73, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 113.42, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Senior Advantage HMO", "plan_name": "Kaiser Permanente Senior Advantage HMO", "standard_charge_dollar": 104.2, "methodology": "fee schedule" }, { "payer_name": "Magellan Devoted Health Plans", "plan_name": "Magellan Devoted Health Plans", "standard_charge_dollar": 109.5, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 113.42, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 115.73, "methodology": "fee schedule" } ], "gross_charge": 850.0, "minimum": 104.2, "maximum": 424.0 } ] }, { "description": "MCR IOP Adult - 2 units", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "52002", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 113.42, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Clear Springs Health Inc", "plan_name": "Clear Springs Health Inc", "standard_charge_dollar": 115.73, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 300.02, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 130.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 130.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 113.42, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 180.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Senior Advantage HMO", "plan_name": "Kaiser Permanente Senior Advantage HMO", "standard_charge_dollar": 102.12, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Devoted Health Plans", "plan_name": "Magellan Devoted Health Plans", "standard_charge_dollar": 109.5, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Pace", "plan_name": "Rocky Mountain Pace", "standard_charge_dollar": 85.8, "methodology": "fee schedule" }, { "payer_name": "SECURE HORIZONS", "plan_name": "SECURE HORIZONS", "standard_charge_dollar": 89.4, "methodology": "fee schedule" }, { "payer_name": "Total Long Term Care", "plan_name": "Total Long Term Care", "standard_charge_dollar": 94.35, "methodology": "fee schedule" }, { "payer_name": "Total Longterm Care INC", "plan_name": "Total Longterm Care INC", "standard_charge_dollar": 94.35, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 94.35, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 113.96, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 113.96, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 113.96, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 113.96, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 94.35, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 104.2, "methodology": "fee schedule" }, { "payer_name": "Wyoming Pace", "plan_name": "Wyoming Pace", "standard_charge_dollar": 89.4, "methodology": "fee schedule" } ], "gross_charge": 850.0, "minimum": 85.8, "maximum": 300.02 } ] }, { "description": "MCR IOP Adult- 3 units", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "52003", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Amerigroup", "plan_name": "Amerigroup", "standard_charge_dollar": 66.95, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 75.62, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Clear Springs Health Inc", "plan_name": "Clear Springs Health Inc", "standard_charge_dollar": 77.15, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 300.02, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Fidelis - Medicare Advantage", "plan_name": "Fidelis - Medicare Advantage", "standard_charge_dollar": 66.95, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 130.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 130.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 314.8, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 180.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Senior Advantage HMO", "plan_name": "Kaiser Permanente Senior Advantage HMO", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Devoted Health Plans", "plan_name": "Magellan Devoted Health Plans", "standard_charge_dollar": 219.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 167.34, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Pace", "plan_name": "Rocky Mountain Pace", "standard_charge_dollar": 314.8, "methodology": "fee schedule" }, { "payer_name": "SECURE HORIZONS", "plan_name": "SECURE HORIZONS", "standard_charge_dollar": 59.6, "methodology": "fee schedule" }, { "payer_name": "Total Long Term Care", "plan_name": "Total Long Term Care", "standard_charge_dollar": 62.9, "methodology": "fee schedule" }, { "payer_name": "Total Longterm Care INC", "plan_name": "Total Longterm Care INC", "standard_charge_dollar": 62.9, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 62.9, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 75.97, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 75.97, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 75.97, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 75.97, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 62.9, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 69.47, "methodology": "fee schedule" }, { "payer_name": "Wyoming Pace", "plan_name": "Wyoming Pace", "standard_charge_dollar": 59.6, "methodology": "fee schedule" } ], "gross_charge": 566.67, "minimum": 59.6, "maximum": 314.8 } ] }, { "description": "MCR IOP Gero CD 2 UNITS", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "70006", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 75.62, "methodology": "fee schedule" }, { "payer_name": "ASI Tricare Retired Supplement", "plan_name": "ASI Tricare Retired Supplement", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "Clear Springs Health Inc", "plan_name": "Clear Springs Health Inc", "standard_charge_dollar": 115.73, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 75.62, "methodology": "fee schedule" }, { "payer_name": "MBA Tricare Supplemental", "plan_name": "MBA Tricare Supplemental", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Pace", "plan_name": "Rocky Mountain Pace", "standard_charge_dollar": 115.73, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 115.73, "methodology": "fee schedule" } ], "gross_charge": 850.0, "minimum": 75.62, "maximum": 275.0 } ] }, { "description": "MCR IOP Gero CD 3 UNITS", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "70007", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 75.62, "methodology": "fee schedule" }, { "payer_name": "ASI Tricare Retired Supplement", "plan_name": "ASI Tricare Retired Supplement", "standard_charge_dollar": 183.34, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 75.62, "methodology": "fee schedule" }, { "payer_name": "MBA Tricare Supplemental", "plan_name": "MBA Tricare Supplemental", "standard_charge_dollar": 183.34, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Pace", "plan_name": "Rocky Mountain Pace", "standard_charge_dollar": 77.15, "methodology": "fee schedule" }, { "payer_name": "Rocky Mtn Pace", "plan_name": "Rocky Mtn Pace", "standard_charge_dollar": 216.51, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 77.15, "methodology": "fee schedule" } ], "gross_charge": 566.67, "minimum": 75.62, "maximum": 216.51 } ] }, { "description": "PHP Daily", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "168000", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 420.98, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health Strategies", "plan_name": "Carelon Behavioral Health Strategies", "standard_charge_dollar": 420.98, "methodology": "fee schedule" }, { "payer_name": "Carelon BH APWU", "plan_name": "Carelon BH APWU", "standard_charge_dollar": 420.98, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Employee Asst", "plan_name": "Carelon BH Employee Asst", "standard_charge_dollar": 420.98, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Great West", "plan_name": "Carelon BH Great West", "standard_charge_dollar": 420.98, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 420.98, "methodology": "fee schedule" }, { "payer_name": "Carelon Health Colorado Medicaid", "plan_name": "Carelon Health Colorado Medicaid", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Medicare Advantage", "plan_name": "Carelon Medicare Advantage", "standard_charge_dollar": 420.98, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 486.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Alliance Health And Life", "plan_name": "Cigna Alliance Health And Life", "standard_charge_dollar": 486.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Health Spring Medicare Advantage", "plan_name": "Cigna Health Spring Medicare Advantage", "standard_charge_dollar": 486.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 261.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Supplemental", "plan_name": "Cigna Supplemental", "standard_charge_dollar": 486.0, "methodology": "fee schedule" }, { "payer_name": "Cigna True Choice Medicare PPO", "plan_name": "Cigna True Choice Medicare PPO", "standard_charge_dollar": 486.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Zenith Administrators", "plan_name": "Cigna Zenith Administrators", "standard_charge_dollar": 486.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 486.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 486.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 280.0, 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255.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Network Group", "plan_name": "Managed Health Network Group", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "MERP Administrative Services", "plan_name": "MERP Administrative Services", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "MHNET", "plan_name": "MHNET", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "Mines And Associates, PC", "plan_name": "Mines And Associates, PC", 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"payer_name": "Pacificare Behavioral Health", "plan_name": "Pacificare Behavioral Health", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "Physicians Mutual Insurance Company", "plan_name": "Physicians Mutual Insurance Company", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "Pinnacol Assurance", "plan_name": "Pinnacol Assurance", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "Preferred One Administrative Services", "plan_name": "Preferred One Administrative Services", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Presbyterian Health Plan", "plan_name": "Presbyterian Health Plan", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "Private Health Care Systems", "plan_name": "Private Health Care Systems", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "Psych Care", "plan_name": "Psych Care", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "Reserve Officers Assoc Insurance", "plan_name": "Reserve Officers Assoc Insurance", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "RMHP HMO Optum", "plan_name": "RMHP HMO Optum", "standard_charge_dollar": 325.0, "methodology": "fee schedule" }, { "payer_name": "RMSCO, Inc", "plan_name": "RMSCO, Inc", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain-Life Strategies", "plan_name": "Rocky Mountain-Life Strategies", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "SECURE HORIZONS", "plan_name": "SECURE HORIZONS", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons (Medicare)", "plan_name": "Secure Horizons (Medicare)", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons Direct", "plan_name": "Secure Horizons Direct", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "Select Benefits Administrators", "plan_name": "Select Benefits Administrators", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Selman Co", "plan_name": "Selman Co", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Sentinel Life Insurance", "plan_name": "Sentinel Life Insurance", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "Sharp Community Med Grp/Secure Horizon", "plan_name": "Sharp Community Med Grp/Secure Horizon", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "Sheet Metal Workers", "plan_name": "Sheet Metal Workers", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "Simplan Insurance", "plan_name": "Simplan Insurance", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Standard Life And Accident Insurance", "plan_name": "Standard Life And Accident Insurance", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "The GEMGroup", "plan_name": "The GEMGroup", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "Travelers Insurance", "plan_name": "Travelers Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Tufts Health Plan", "plan_name": "Tufts Health Plan", "standard_charge_dollar": 479.0, "methodology": "fee schedule" }, { "payer_name": "UMR/CEBT-PM085516", "plan_name": "UMR/CEBT-PM085516", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "UPMC Health Plan", "plan_name": "UPMC Health Plan", "standard_charge_dollar": 486.0, "methodology": "fee schedule" }, { "payer_name": "Winhealth", "plan_name": "Winhealth", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Wyoming Pace", "plan_name": "Wyoming Pace", "standard_charge_dollar": 224.27, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 150.0, "maximum": 650.0 } ] }, { "description": "Telehealth Tri/Medi Psych Adult IOP-2 units", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "827", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 302.0, "methodology": "fee schedule" } ], "gross_charge": 850.0, "minimum": 302.0, "maximum": 302.0 } ] }, { "description": "Telehealth Tri/Medi Psych Adult IOP-3 units", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "828", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Medicare Advantage", 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"fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 65.6, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 176.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 65.6, "maximum": 176.0 } ] }, { "description": "TRI ADOL CD PHP 4 UNITS", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "70024", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 67.57, "methodology": "fee schedule" }, { "payer_name": "ASI Tricare Retired Supplement", "plan_name": "ASI Tricare Retired Supplement", "standard_charge_dollar": 49.2, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 132.5, "methodology": "fee 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"methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 49.2, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 49.2, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 132.5, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 49.2, "maximum": 132.5 } ] }, { "description": "TRI ADOL CD PHP 5 UNITS", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "70025", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 54.06, "methodology": "fee schedule" }, { "payer_name": "ASI Tricare Retired Supplement", "plan_name": "ASI Tricare Retired Supplement", 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"payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 49.2, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 49.2, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 49.2, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 49.2, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 49.2, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 49.2, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 132.5, "methodology": "fee schedule" } ], 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"methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 39.36, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 39.36, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 39.36, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 39.36, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 39.36, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 39.36, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 39.36, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 39.36, "maximum": 106.0 } ] }, { "description": "TRI/MCR GERO CD PHP 3 UNITS", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "70014", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 90.09, "methodology": "fee schedule" }, { "payer_name": "ASI Tricare Retired Supplement", "plan_name": "ASI Tricare Retired Supplement", "standard_charge_dollar": 65.6, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 176.0, "methodology": "fee schedule" }, { "payer_name": "Humana Tricare East", "plan_name": "Humana Tricare East", "standard_charge_dollar": 65.6, "methodology": "fee schedule" }, { "payer_name": "MBA Tricare Supplemental", "plan_name": "MBA Tricare Supplemental", "standard_charge_dollar": 65.6, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 65.6, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 65.6, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 65.6, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 65.6, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 65.6, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 65.6, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 65.6, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 176.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 65.6, "maximum": 176.0 } ] }, { "description": "TRI/MCR GERO CD PHP 4 UNITS", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "70015", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 67.57, "methodology": "fee schedule" }, { "payer_name": "ASI Tricare Retired Supplement", "plan_name": "ASI Tricare Retired Supplement", "standard_charge_dollar": 49.2, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 132.5, "methodology": "fee schedule" }, { "payer_name": "Humana Tricare East", "plan_name": "Humana Tricare East", "standard_charge_dollar": 49.2, "methodology": "fee schedule" }, { "payer_name": "MBA Tricare Supplemental", "plan_name": "MBA Tricare Supplemental", "standard_charge_dollar": 49.2, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 49.2, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 49.2, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 49.2, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 49.2, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 49.2, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 49.2, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 49.2, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 132.5, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 49.2, "maximum": 132.5 } ] }, { "description": "TRI/MCR GERO CD PHP 5 UNITS", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "70016", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 54.06, "methodology": "fee schedule" }, { "payer_name": "ASI Tricare Retired Supplement", "plan_name": "ASI Tricare Retired Supplement", "standard_charge_dollar": 39.36, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 106.0, "methodology": "fee schedule" }, { "payer_name": "Humana Tricare East", "plan_name": "Humana Tricare East", "standard_charge_dollar": 39.36, "methodology": "fee schedule" }, { "payer_name": "MBA Tricare Supplemental", "plan_name": "MBA Tricare Supplemental", "standard_charge_dollar": 39.36, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 39.36, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 39.36, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 39.36, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 39.36, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 39.36, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 39.36, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 39.36, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 106.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 39.36, "maximum": 106.0 } ] }, { "description": "Tri/Med Adult PHP - 5 unit", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "2035", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 54.06, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 54.06, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 435.6, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 106.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 37.78, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 120.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 52.64, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Of Washington", "plan_name": "Molina Healthcare Of Washington", "standard_charge_dollar": 170.0, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 35.89, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 187.76, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 35.89, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 35.89, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 35.89, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 39.48, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 197.64, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 106.0, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 170.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 35.89, "maximum": 500.0 } ] }, { "description": "Tri/Medi Adult PHP - 1 unit", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "2031", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 270.26, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 270.26, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 435.6, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 530.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 188.88, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 263.16, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 167.11, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 167.11, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 167.11, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 167.11, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 167.11, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 167.11, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 175.9, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 530.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 167.11, "maximum": 530.0 } ] }, { "description": "Tri/Medi Adult PHP - 2 unit", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "2032", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 135.13, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 135.13, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Health Spring Medicare Advantage", "plan_name": "Cigna Health Spring Medicare Advantage", "standard_charge_dollar": 135.13, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna True Choice Medicare PPO", "plan_name": "Cigna True Choice Medicare PPO", "standard_charge_dollar": 135.13, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 435.6, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 265.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 94.34, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 131.58, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 83.55, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 167.11, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 83.55, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 83.55, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 83.55, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 98.69, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 175.9, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 265.0, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 116.74, "methodology": "fee schedule" } ], "gross_charge": 1250.0, "minimum": 83.55, "maximum": 500.0 } ] }, { "description": "Tri/Medi Adult PHP - 3 unit", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "2033", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 90.09, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 90.09, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Carelon Medicare Advantage", "plan_name": "Carelon Medicare Advantage", "standard_charge_dollar": 90.09, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Health Spring Medicare Advantage", "plan_name": "Cigna Health Spring Medicare Advantage", "standard_charge_dollar": 90.09, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna True Choice Medicare PPO", "plan_name": "Cigna True Choice Medicare PPO", "standard_charge_dollar": 90.09, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 435.6, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 176.66, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 62.96, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 87.72, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Of Washington", "plan_name": "Molina Healthcare Of Washington", "standard_charge_dollar": 283.33, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 54.76, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 167.11, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 54.76, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 54.76, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 54.76, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 56.74, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 175.9, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 176.67, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 79.42, "methodology": "fee schedule" } ], "gross_charge": 833.33, "minimum": 54.76, "maximum": 500.0 } ] }, { "description": "Tri/Medi Adult PHP - 4 unit", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "2034", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare Advantage", "plan_name": "Aetna Medicare Advantage", "standard_charge_dollar": 67.57, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 67.57, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Health Spring Medicare Advantage", "plan_name": "Cigna Health Spring Medicare Advantage", "standard_charge_dollar": 67.57, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna True Choice Medicare PPO", "plan_name": "Cigna True Choice Medicare PPO", "standard_charge_dollar": 67.57, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 435.6, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 132.5, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 47.22, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 150.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 65.79, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Of Washington", "plan_name": "Molina Healthcare Of Washington", "standard_charge_dollar": 212.5, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 44.86, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 187.76, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 44.86, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 44.86, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 44.86, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 49.35, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 197.64, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 132.5, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 59.56, "methodology": "fee schedule" } ], "gross_charge": 625.0, "minimum": 44.86, "maximum": 500.0 } ] }, { "description": "Tri/Medi Child/Adol PHP - 1 un", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "2001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 270.26, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "BCBS HMO Colorado", "plan_name": "BCBS HMO Colorado", "standard_charge_dollar": 546.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 435.6, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 530.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 188.88, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 167.11, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 167.11, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 167.11, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 167.11, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 167.11, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 167.11, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 175.9, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 530.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 167.11, "maximum": 546.0 } ] }, { "description": "Tri/Medi Child/Adol PHP - 2 un", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "2002", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 135.13, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 435.6, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 265.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 94.34, "methodology": "fee schedule" }, { 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schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 83.55, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 65.79, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 175.9, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 265.0, "methodology": "fee schedule" } ], "gross_charge": 1250.0, "minimum": 65.79, "maximum": 500.0 } ] }, { "description": "Tri/Medi Child/Adol PHP - 3 un", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "2003", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 227.92, "methodology": 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"plan_name": "Tricare North Region", "standard_charge_dollar": 54.76, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 54.76, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 54.76, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 56.74, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 175.9, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 176.67, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 79.42, "methodology": "fee schedule" } ], "gross_charge": 833.33, 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"methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", 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345.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { 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"Tricare-WPS", "standard_charge_dollar": 197.64, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 59.56, "methodology": "fee schedule" } ], "gross_charge": 625.0, "minimum": 44.86, "maximum": 500.0 } ] }, { "description": "Tri/Medi Child/Adol PHP- 5 un", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "2005", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": 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"methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 280.0, 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Mountain Health", "standard_charge_dollar": 435.6, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", 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"methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 35.89, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 187.76, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 35.89, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 35.89, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 35.89, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 39.48, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 197.64, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 106.0, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 47.65, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 35.89, "maximum": 500.0 } ] }, { "description": "Tri/Medi Gero IOP - 2 unit", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "6352", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 113.42, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 229.0, "methodology": "fee schedule" }, { "payer_name": "Clear Springs Health Inc", "plan_name": "Clear Springs Health Inc", "standard_charge_dollar": 115.73, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 113.42, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 100.63, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Pace", "plan_name": "Rocky Mountain Pace", "standard_charge_dollar": 100.43, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 170.21, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 104.2, "methodology": "fee schedule" } ], "gross_charge": 850.0, "minimum": 100.43, "maximum": 229.0 } ] }, { "description": "Tri/Medi Gero IOP - 3 unit", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "6353", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Amerigroup", "plan_name": "Amerigroup", "standard_charge_dollar": 66.95, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 75.62, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 66.95, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 229.0, "methodology": "fee schedule" }, { "payer_name": "Clear Springs Health Inc", "plan_name": "Clear Springs Health Inc", "standard_charge_dollar": 77.15, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 75.62, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 67.09, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Pace", "plan_name": "Rocky Mountain Pace", "standard_charge_dollar": 54.0, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 170.21, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 69.47, "methodology": "fee schedule" } ], "gross_charge": 566.67, "minimum": 54.0, "maximum": 229.0 } ] }, { "description": "Tri/Medi Gero PHP - 1 unit", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "167001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Blue Cross Blue Shield", "plan_name": "Blue Cross Blue Shield", "standard_charge_dollar": 873.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 435.6, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "SECURE HORIZONS", "plan_name": "SECURE HORIZONS", "standard_charge_dollar": 224.27, "methodology": "fee schedule" }, { "payer_name": "Total Long Term Care", "plan_name": "Total Long Term Care", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "Total Longterm Care INC", "plan_name": "Total Longterm Care INC", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 175.9, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 167.11, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 175.9, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 175.9, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 175.9, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 167.11, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 175.9, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Wyoming Pace", "plan_name": "Wyoming Pace", "standard_charge_dollar": 224.27, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 167.11, "maximum": 873.0 } ] }, { "description": "Tri/Medi Gero PHP - 1 units", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "6251", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 270.26, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 263.16, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "Clear Springs Health Inc", "plan_name": "Clear Springs Health Inc", "standard_charge_dollar": 234.43, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 530.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 263.16, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 263.16, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 197.37, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 530.0, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 234.43, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 197.37, "maximum": 530.0 } ] }, { "description": "Tri/Medi Gero PHP - 2 units", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "6252", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 131.58, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Clear Springs Health Inc", "plan_name": "Clear Springs Health Inc", "standard_charge_dollar": 117.22, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 435.6, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 265.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", 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"standard_charge_dollar": 175.9, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 175.9, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 175.9, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 197.37, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 175.9, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 265.0, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 117.22, "methodology": "fee schedule" }, { "payer_name": "Wyoming Pace", "plan_name": "Wyoming Pace", "standard_charge_dollar": 112.13, "methodology": "fee schedule" } ], "gross_charge": 1250.0, "minimum": 94.35, "maximum": 500.0 } ] }, { "description": "Tri/Medi Gero PHP - 3 units", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "6253", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Amerigroup", "plan_name": "Amerigroup", "standard_charge_dollar": 68.15, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 87.72, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { 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schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Clear Springs Health Inc", "plan_name": "Clear Springs Health Inc", "standard_charge_dollar": 78.15, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 435.6, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Fidelis - Medicare Advantage", "plan_name": "Fidelis - Medicare Advantage", "standard_charge_dollar": 68.15, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 176.0, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Pace", "plan_name": "Rocky Mountain Pace", "standard_charge_dollar": 283.33, "methodology": "fee schedule" }, { "payer_name": "SECURE HORIZONS", "plan_name": "SECURE HORIZONS", "standard_charge_dollar": 74.75, "methodology": "fee schedule" }, { "payer_name": "Total Long Term Care", "plan_name": "Total Long Term Care", "standard_charge_dollar": 62.9, "methodology": "fee schedule" }, { "payer_name": "Total Longterm Care INC", "plan_name": "Total Longterm Care INC", "standard_charge_dollar": 62.9, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 175.9, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 167.11, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 175.9, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 175.9, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 175.9, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 167.11, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 175.9, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 176.66, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 78.15, "methodology": "fee schedule" }, { "payer_name": "Wyoming Pace", "plan_name": "Wyoming Pace", "standard_charge_dollar": 74.75, "methodology": "fee schedule" } ], "gross_charge": 833.33, "minimum": 62.9, "maximum": 500.0 } ] }, { "description": "Tri/Medi Gero PHP - 4 units", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "6254", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Amerigroup", "plan_name": "Amerigroup", "standard_charge_dollar": 51.11, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Medicare Advantage", "plan_name": "Anthem BCBS Medicare Advantage", "standard_charge_dollar": 65.79, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Assurant Health", "plan_name": "Assurant Health", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Inc", "plan_name": "Behavioral Health Inc", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Care Source", "plan_name": "Care Source", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 359.0, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Cigna", "plan_name": "Cigna", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Clear Springs Health Inc", "plan_name": "Clear Springs Health Inc", "standard_charge_dollar": 58.61, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 435.6, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Fidelis - Medicare Advantage", "plan_name": "Fidelis - Medicare Advantage", "standard_charge_dollar": 51.11, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 255.0, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "HNFS Tricare West", "plan_name": "HNFS Tricare West", "standard_charge_dollar": 132.5, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain Pace", "plan_name": "Rocky Mountain Pace", "standard_charge_dollar": 212.5, "methodology": "fee schedule" }, { "payer_name": "SECURE HORIZONS", "plan_name": "SECURE HORIZONS", "standard_charge_dollar": 56.06, "methodology": "fee schedule" }, { "payer_name": "Total Long Term Care", "plan_name": "Total Long Term Care", "standard_charge_dollar": 47.17, "methodology": "fee schedule" }, { "payer_name": "Total Longterm Care INC", "plan_name": "Total Longterm Care INC", "standard_charge_dollar": 47.17, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 197.64, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 187.76, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 197.64, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 197.64, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 197.64, "methodology": "fee schedule" }, { 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"AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": 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Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 435.6, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": 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13", "standard_charge_dollar": 197.64, "methodology": "fee schedule" }, { "payer_name": "TriCare For Life", "plan_name": "TriCare For Life", "standard_charge_dollar": 187.76, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 197.64, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 197.64, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 197.64, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 187.76, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 197.64, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 106.0, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 46.89, "methodology": "fee schedule" }, { "payer_name": "Wyoming Pace", "plan_name": "Wyoming Pace", "standard_charge_dollar": 44.85, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 37.74, "maximum": 500.0 } ] }, { "description": "TRICARE PHP Daily", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "169002", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "American Family Ins", "plan_name": "American Family Ins", "standard_charge_dollar": 188.69, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": 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"standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Cofinity", "plan_name": "Cofinity", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Colorado Access Advantage", "plan_name": "Colorado Access Advantage", "standard_charge_dollar": 280.0, "methodology": "fee schedule" }, { "payer_name": "Coventry Health Care", "plan_name": "Coventry Health Care", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Cover Colorado Rocky Mountain Health", "plan_name": "Cover Colorado Rocky Mountain Health", "standard_charge_dollar": 435.6, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 227.92, "methodology": "fee schedule" }, { "payer_name": "EBMS", "plan_name": "EBMS", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "FMH Benefit Services", "plan_name": "FMH Benefit Services", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 345.0, "methodology": "fee 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{ "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 375.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 227.92, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 188.69, "maximum": 500.0 } ] }, { "description": "DC <30 minutes", "code_information": [ { "code": "99238", "type": "CPT" }, { "code": "99238", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health Strategies", "plan_name": "Carelon Behavioral Health Strategies", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Carelon BH APWU", "plan_name": "Carelon BH APWU", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Employee Asst", "plan_name": "Carelon BH Employee Asst", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Great West", "plan_name": "Carelon BH Great West", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Carelon Health Colorado Medicaid", "plan_name": "Carelon Health Colorado Medicaid", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 33.24, "methodology": "fee schedule" }, { "payer_name": "Equitable Life And Casualty Insurance Co", "plan_name": "Equitable Life And Casualty Insurance Co", "standard_charge_dollar": 33.24, "methodology": "fee schedule" }, { "payer_name": "Evercare - Medicaid New Mexico", "plan_name": "Evercare - Medicaid New Mexico", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Friday Health Plans", "plan_name": "Friday Health Plans", "standard_charge_dollar": 33.24, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Group Benefits", "plan_name": "Group Benefits", "standard_charge_dollar": 33.24, "methodology": "fee schedule" }, { "payer_name": "Harvard Pilgrim HealthCare", "plan_name": "Harvard Pilgrim HealthCare", "standard_charge_dollar": 33.24, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "HWBS Claims", "plan_name": "HWBS Claims", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente", "plan_name": "Kaiser 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300.0, "methodology": "fee schedule" }, { "payer_name": "Medica Elect", "plan_name": "Medica Elect", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 108.36, "methodology": "fee schedule" }, { "payer_name": "Motivhealth", "plan_name": "Motivhealth", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Mountain Health Co-op", "plan_name": "Mountain Health Co-op", "standard_charge_dollar": 150.0, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Insurance", "plan_name": "Select Health Insurance", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Medicare Adv", "plan_name": "Select Health Medicare Adv", "standard_charge_dollar": 108.36, "methodology": "fee schedule" }, { "payer_name": "State Of Co Probation", "plan_name": "State Of Co Probation", "standard_charge_dollar": 150.0, "methodology": "fee schedule" }, { "payer_name": "Surest - United Health Care", "plan_name": "Surest - United Health Care", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Triwest Tricare", "plan_name": "Triwest Tricare", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Triwest VA CCN Claims", "plan_name": "Triwest VA CCN Claims", "standard_charge_dollar": 108.36, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 150.0, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "United Health Care New Mexico", "plan_name": "United Health Care New Mexico", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Student Resources", "plan_name": "United Healthcare Student Resources", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Supplement", "plan_name": "United Healthcare Supplement", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "United Select Health", "plan_name": "United Select Health", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "United World Life", "plan_name": "United World Life", "standard_charge_dollar": 300.0, "methodology": "fee schedule" } ], "gross_charge": 400.0, "minimum": 87.88, "maximum": 400.0 } ] }, { "description": "Indiv Psych Therapy", "code_information": [ { "code": "90837", "type": "CPT" }, { "code": "90804", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "State Of Co Probation", "plan_name": "State Of Co Probation", "standard_charge_dollar": 50.0, "methodology": "fee schedule" } ], "gross_charge": 60.0, "minimum": 50.0, "maximum": 50.0 } ] }, { "description": "INDIVIDUAL PSYCHOTHERAPY", "code_information": [ { "code": "90837", "type": "CPT" }, { "code": "90837", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem BCBS Personal Choice", "plan_name": "Anthem BCBS Personal Choice", "standard_charge_dollar": 106.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Blue Cross Blue Shield", "plan_name": "Anthem Blue Cross Blue Shield", "standard_charge_dollar": 106.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi Blue Of Ohio", "plan_name": "Anthem Medi Blue Of Ohio", "standard_charge_dollar": 106.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medi-Blue", "plan_name": "Anthem Medi-Blue", "standard_charge_dollar": 106.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Mediblue Dual Advantage", "plan_name": "Anthem Mediblue Dual Advantage", "standard_charge_dollar": 106.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 55.0, "methodology": "fee schedule" }, { 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"standard_charge_dollar": 55.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Northeast Health Partners Mcaid", "plan_name": "Carelon Northeast Health Partners Mcaid", "standard_charge_dollar": 94.71, "methodology": "fee schedule" }, { "payer_name": "Colo Community Health Alliance", "plan_name": "Colo Community Health Alliance", "standard_charge_dollar": 130.4, "methodology": "fee schedule" }, { "payer_name": "Colorado Access", "plan_name": "Colorado Access", "standard_charge_dollar": 130.0, "methodology": "fee schedule" }, { "payer_name": "Huntsman Mental Health Institute - BHN", "plan_name": "Huntsman Mental Health Institute - BHN", "standard_charge_dollar": 106.0, "methodology": "fee schedule" }, { "payer_name": "Mountain Health Co-op", "plan_name": "Mountain Health Co-op", "standard_charge_dollar": 106.0, "methodology": "fee schedule" }, { "payer_name": "Northeast HP- RMHP", "plan_name": "Northeast HP- RMHP", "standard_charge_dollar": 94.71, "methodology": "fee 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"payer_name": "Neighborhood Health Plan", "plan_name": "Neighborhood Health Plan", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "OPTUM EMPIRE HEALTH PLAN", "plan_name": "OPTUM EMPIRE HEALTH PLAN", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Pacificare Behavioral Health", "plan_name": "Pacificare Behavioral Health", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Psych Care", "plan_name": "Psych Care", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "RMSCO, Inc", "plan_name": "RMSCO, Inc", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain-Life Strategies", "plan_name": "Rocky Mountain-Life Strategies", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "SECURE HORIZONS", "plan_name": "SECURE HORIZONS", "standard_charge_dollar": 113.84, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons (Medicare)", "plan_name": "Secure Horizons (Medicare)", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons Direct", "plan_name": "Secure Horizons Direct", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Select Benefits Administrators", "plan_name": "Select Benefits Administrators", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Selman Co", "plan_name": "Selman Co", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Sharp Community Med Grp/Secure Horizon", "plan_name": "Sharp Community Med Grp/Secure Horizon", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Standard Life And Accident Insurance", "plan_name": "Standard Life And Accident Insurance", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Total Long Term Care", "plan_name": "Total Long Term Care", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Total Longterm Care INC", "plan_name": "Total Longterm Care INC", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Travelers Insurance", "plan_name": "Travelers Insurance", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "UMR/CEBT-PM085516", "plan_name": "UMR/CEBT-PM085516", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Wyoming Pace", "plan_name": "Wyoming Pace", "standard_charge_dollar": 113.84, "methodology": "fee schedule" } ], "gross_charge": 220.0, "minimum": 75.0, "maximum": 113.84 } ] }, { "description": "INIT HOSP CARE 50 MIN", "code_information": [ { "code": "99222", "type": "CPT" }, { "code": "99222", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 112.44, 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"standard_charge_dollar": 31.9, "methodology": "fee schedule" }, { "payer_name": "Colo Community Health Alliance", "plan_name": "Colo Community Health Alliance", "standard_charge_dollar": 23.46, "methodology": "fee schedule" }, { "payer_name": "Huntsman Mental Health Institute - BHN", "plan_name": "Huntsman Mental Health Institute - BHN", "standard_charge_dollar": 44.0, "methodology": "fee schedule" }, { "payer_name": "Mountain Health Co-op", "plan_name": "Mountain Health Co-op", "standard_charge_dollar": 44.0, "methodology": "fee schedule" }, { "payer_name": "Northeast HP- RMHP", "plan_name": "Northeast HP- RMHP", "standard_charge_dollar": 31.9, "methodology": "fee schedule" }, { "payer_name": "Select Health Insurance", "plan_name": "Select Health Insurance", "standard_charge_dollar": 85.0, "methodology": "fee schedule" }, { "payer_name": "Select Health Medicare Adv", "plan_name": "Select Health Medicare Adv", "standard_charge_dollar": 85.0, "methodology": "fee schedule" }, { "payer_name": "State Of Co Probation", "plan_name": "State Of Co Probation", "standard_charge_dollar": 44.0, "methodology": "fee schedule" } ], "gross_charge": 100.0, "minimum": 23.46, "maximum": 85.0 } ] }, { "description": "SUBSEQ HOSP (25 MIN)", "code_information": [ { "code": "99232", "type": "CPT" }, { "code": "99232", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health Strategies", "plan_name": "Carelon Behavioral Health Strategies", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Carelon BH APWU", "plan_name": "Carelon BH APWU", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Employee Asst", "plan_name": "Carelon BH Employee Asst", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Great West", "plan_name": "Carelon BH Great West", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Carelon Health Colorado Medicaid", "plan_name": "Carelon Health Colorado Medicaid", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Evercare - Medicaid New Mexico", "plan_name": "Evercare - Medicaid New Mexico", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "HWBS Claims", "plan_name": "HWBS Claims", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente", "plan_name": "Kaiser Permanente", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Denver", "plan_name": "Kaiser Permanente Denver", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Northern", "plan_name": "Kaiser Permanente Northern", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Senior Advantage HMO", "plan_name": "Kaiser Permanente Senior Advantage HMO", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente/KPIC", "plan_name": "Kaiser Permanente/KPIC", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "M-Care Medical Network", "plan_name": "M-Care Medical Network", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Magellan Health Services", "plan_name": "Magellan Health Services", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Mailhandlers", "plan_name": "Mailhandlers", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Managed Health Network Group", "plan_name": "Managed Health Network Group", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Medicaid United Healthcare", "plan_name": "Medicaid United Healthcare", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Medicare United HealthCare", "plan_name": "Medicare United HealthCare", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "MHNET", "plan_name": "MHNET", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Mines And Associates, PC", "plan_name": "Mines And Associates, PC", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Nationwide Life", "plan_name": "Nationwide Life", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Neighborhood Health Plan", "plan_name": "Neighborhood Health Plan", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Network Health VA", "plan_name": "Network Health VA", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "OPTUM EMPIRE HEALTH PLAN", "plan_name": "OPTUM EMPIRE HEALTH PLAN", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Oxford Health - United Behavioral Health", "plan_name": "Oxford Health - United Behavioral Health", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Pacificare Behavioral Health", "plan_name": "Pacificare Behavioral Health", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Psych Care", "plan_name": "Psych Care", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "RMSCO, Inc", "plan_name": "RMSCO, Inc", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Rocky Mountain-Life Strategies", "plan_name": "Rocky Mountain-Life Strategies", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "SECURE HORIZONS", "plan_name": "SECURE HORIZONS", "standard_charge_dollar": 113.84, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons (Medicare)", "plan_name": "Secure Horizons (Medicare)", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Secure Horizons Direct", "plan_name": "Secure Horizons Direct", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Select Benefits Administrators", "plan_name": "Select Benefits Administrators", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Selman Co", "plan_name": "Selman Co", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Sharp Community Med Grp/Secure Horizon", "plan_name": "Sharp Community Med Grp/Secure Horizon", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Standard Life And Accident Insurance", "plan_name": "Standard Life And Accident Insurance", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Total Long Term Care", "plan_name": "Total Long Term Care", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Total Longterm Care INC", "plan_name": "Total Longterm Care INC", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Travelers Insurance", "plan_name": "Travelers Insurance", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "UMR/CEBT-PM085516", "plan_name": "UMR/CEBT-PM085516", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Wyoming Pace", "plan_name": "Wyoming Pace", "standard_charge_dollar": 113.84, "methodology": "fee schedule" } ], "gross_charge": 200.0, "minimum": 75.0, "maximum": 113.84 } ] }, { "description": "SUBSEQ HOSP (35 MIN)", "code_information": [ { "code": "99233", "type": "CPT" }, { "code": "99233", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Aetna Senior Supplemental Ins", "plan_name": "Aetna Senior Supplemental Ins", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan", "plan_name": "Allegiance Benefit Plan", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Allianz Global Assistance", "plan_name": "Allianz Global Assistance", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Ameriben", "plan_name": "Ameriben", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "American Republic Insurance", "plan_name": "American Republic Insurance", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "APWU Health Plan", "plan_name": "APWU Health Plan", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Barrick Gold Corp", "plan_name": "Barrick Gold Corp", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Blue Card Nasco", "plan_name": "Blue Card Nasco", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Bridge Point", "plan_name": "Bridge Point", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health Strategies", "plan_name": "Carelon Behavioral Health Strategies", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Carelon BH APWU", "plan_name": "Carelon BH APWU", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Employee Asst", "plan_name": "Carelon BH Employee Asst", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Great West", "plan_name": "Carelon BH Great West", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Carelon BH Kaiser", "plan_name": "Carelon BH Kaiser", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Carelon Health Colorado Medicaid", "plan_name": "Carelon Health Colorado Medicaid", "standard_charge_dollar": 75.0, "methodology": "fee schedule" }, { "payer_name": "ChampVA", "plan_name": "ChampVA", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Cigna International", "plan_name": "Cigna International", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Cigna/GreatWest Healthcare", "plan_name": "Cigna/GreatWest Healthcare", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Cigna/Health Partners Inc", "plan_name": "Cigna/Health Partners Inc", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "CNIC", "plan_name": "CNIC", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Denver Health Medical Plan", "plan_name": "Denver Health Medical Plan", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Deseret Healthcare Employee", "plan_name": "Deseret Healthcare Employee", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Evercare - Medicaid New Mexico", "plan_name": "Evercare - Medicaid New Mexico", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "First Health", "plan_name": "First Health", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "GEHA", "plan_name": "GEHA", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "GEHA-Untied Hlth Integrated Serv", "plan_name": "GEHA-Untied Hlth Integrated Serv", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Golden Rule/UHC", "plan_name": "Golden Rule/UHC", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "HealthChoice", "plan_name": "HealthChoice", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "HealthScope Benefits Inc", "plan_name": "HealthScope Benefits Inc", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Humana Gold Choice", "plan_name": "Humana Gold Choice", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Humana Healthcare", "plan_name": "Humana Healthcare", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "HWBS Claims", "plan_name": "HWBS Claims", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente", "plan_name": "Kaiser Permanente", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Denver", "plan_name": "Kaiser Permanente Denver", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente Northern", "plan_name": "Kaiser Permanente 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"standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 112.44, "methodology": "fee schedule" }, { "payer_name": "Wyoming Pace", "plan_name": "Wyoming Pace", "standard_charge_dollar": 85.54, "methodology": "fee schedule" } ], "gross_charge": 200.0, "minimum": 75.0, "maximum": 112.44 } ] }, { "description": "SUBSEQ HOSP (15 MIN)", "code_information": [ { "code": "99231", "type": "CPT" }, { "code": "99231", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Administrative District Council 1 Welfar", "plan_name": "Administrative District Council 1 Welfar", "standard_charge_dollar": 130.17, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Aetna AMA Travel Insurance", "plan_name": "Aetna AMA Travel Insurance", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Aetna Healthcare", "plan_name": "Aetna Healthcare", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { 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schedule" }, { "payer_name": "Selman And Company", "plan_name": "Selman And Company", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Selman Co", "plan_name": "Selman Co", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Sharp Community Med Grp/Secure Horizon", "plan_name": "Sharp Community Med Grp/Secure Horizon", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Standard Life And Accident Insurance", "plan_name": "Standard Life And Accident Insurance", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Total Long Term Care", "plan_name": "Total Long Term Care", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Total Longterm Care INC", "plan_name": "Total Longterm Care INC", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Travelers Insurance", "plan_name": "Travelers Insurance", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Tricare Europe Region 13", "plan_name": "Tricare Europe Region 13", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Tricare North Region", "plan_name": "Tricare North Region", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Tricare Pacific Region 14", "plan_name": "Tricare Pacific Region 14", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Tricare South Region", "plan_name": "Tricare South Region", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Tricare West-United Healthcare", "plan_name": "Tricare West-United Healthcare", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Tricare-WPS", "plan_name": "Tricare-WPS", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Trustmark Small Business Benefits", "plan_name": "Trustmark Small Business Benefits", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "UMR/CEBT-PM085516", "plan_name": "UMR/CEBT-PM085516", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "UMR/United Healthcare", "plan_name": "UMR/United Healthcare", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "United American Insurance CO", "plan_name": "United American Insurance CO", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health Of California", "plan_name": "United Behavioral Health Of California", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "United Health Care", "plan_name": "United Health Care", "standard_charge_dollar": 32.26, "methodology": "fee schedule" }, { "payer_name": "Wyoming Pace", "plan_name": "Wyoming Pace", "standard_charge_dollar": 32.26, "methodology": "fee schedule" } ], "gross_charge": 140.0, "minimum": 32.26, "maximum": 130.17 } ] } ] }