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12-month lookback period."},{"payer_name":"United","plan_name":"Commercial|Non-Options","standard_charge_dollar":35.92,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"Commercial|Options","standard_charge_dollar":35.92,"methodology":"fee schedule"},{"payer_name":"BCBS - TN","plan_name":"Medicaid|BlueCare","standard_charge_dollar":0.01,"standard_charge_algorithm": "Lesser of $46.57 or 100 Percent of Billed Charges","count":"0","methodology":"fee schedule", "additional_payer_notes": "No services performed during 12-month lookback period."},{"payer_name":"Peach State","plan_name":"Medicaid|All Plans","standard_charge_dollar":35.91,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"Medicaid|TennCare","standard_charge_dollar":25.14,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"Medicare|All Plans","standard_charge_dollar":0.02,"standard_charge_algorithm": "Lesser of $38.43 or 107 Percent of Billed Charges","count":"0","methodology":"fee schedule", "additional_payer_notes": "No services performed during 12-month lookback period."},{"payer_name":"BCBS - ND","plan_name":"Medicare|All Plans","standard_charge_dollar":0.02,"standard_charge_algorithm": "Lesser of $37.36 or 104 Percent of Billed Charges","count":"0","methodology":"fee schedule", "additional_payer_notes": "No services performed during 12-month lookback period."},{"payer_name":"Cigna","plan_name":"Medicare|Healthspring","standard_charge_dollar":0.02,"standard_charge_algorithm": "Lesser of $37.72 or 105 Percent of Billed Charges","count":"0","methodology":"fee schedule", "additional_payer_notes": "No services performed during 12-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare|All Other Plans","standard_charge_dollar":0.02,"standard_charge_algorithm": "Lesser of $39.51 or 110 Percent of Billed Charges","count":"0","methodology":"fee schedule", "additional_payer_notes": "No services performed during 12-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare|HMO","standard_charge_dollar":0.02,"standard_charge_algorithm": "Lesser of $38.08 or 106 Percent of Billed Charges","count":"0","methodology":"fee schedule", "additional_payer_notes": "No services performed during 12-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare|PPO","standard_charge_dollar":0.02,"standard_charge_algorithm": "Lesser of $39.51 or 110 Percent of Billed Charges","count":"0","methodology":"fee schedule", "additional_payer_notes": "No services performed during 12-month lookback period."}]}]},{"description":"HC COVID-19","code_information":[{"code":"U0002","type":"HCPCS"},{"code":"0300","type":"RC"}],"standard_charges":[{"gross_charge":228,"discounted_cash":67.49,"setting":"inpatient","additional_generic_notes":"Not separately reimbursable and/or included in pricing for other item/service listed"}]},{"description":"HC COVID-19","code_information":[{"code":"U0002","type":"HCPCS"},{"code":"0300","type":"RC"}],"standard_charges":[{"minimum":35.92,"maximum":159.6,"gross_charge":228,"discounted_cash":67.49,"setting":"outpatient","payers_information":[{"payer_name":"Aetna","plan_name":"Commercial|Gatekeeper","standard_charge_dollar":159.6,"methodology":"fee schedule"},{"payer_name":"Aetna","plan_name":"Commercial|Non-Gatekeeper","standard_charge_dollar":159.6,"methodology":"fee schedule"},{"payer_name":"BCBS - TN","plan_name":"Commercial|Network P","standard_charge_dollar":113.91,"methodology":"fee schedule"},{"payer_name":"BCBS - TN","plan_name":"Commercial|Network S","standard_charge_dollar":90.31,"methodology":"fee schedule"},{"payer_name":"Centene","plan_name":"Commercial|Ambetter Exchange","standard_charge_dollar":96.46,"standard_charge_algorithm": "Lesser of $96.46 or 188 Percent of Billed Charges","count":"0","methodology":"fee schedule", "additional_payer_notes": "No services performed during 12-month lookback period."},{"payer_name":"United","plan_name":"Commercial|Non-Options","standard_charge_dollar":51.31,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"Commercial|Options","standard_charge_dollar":51.31,"methodology":"fee schedule"},{"payer_name":"BCBS - TN","plan_name":"Medicaid|BlueCare","standard_charge_dollar":66.53,"standard_charge_algorithm": "Lesser of $66.53 or 100 Percent of Billed Charges","median_amount":66.53,"10th_percentile":66.53,"90th_percentile":66.53,"count":"1 through 10","methodology":"fee schedule"},{"payer_name":"Peach State","plan_name":"Medicaid|All Plans","standard_charge_dollar":51.31,"methodology":"fee schedule"},{"payer_name":"United","plan_name":"Medicaid|TennCare","standard_charge_dollar":35.92,"methodology":"fee schedule"},{"payer_name":"Amerigroup","plan_name":"Medicare|All Plans","standard_charge_dollar":54.9,"standard_charge_algorithm": "Lesser of $54.90 or 107 Percent of Billed Charges","count":"0","methodology":"fee schedule", "additional_payer_notes": "No services performed during 12-month lookback period."},{"payer_name":"BCBS - ND","plan_name":"Medicare|All Plans","standard_charge_dollar":53.36,"standard_charge_algorithm": "Lesser of $53.36 or 104 Percent of Billed Charges","median_amount":53.36,"10th_percentile":53.36,"90th_percentile":53.36,"count":"1 through 10","methodology":"fee schedule"},{"payer_name":"Cigna","plan_name":"Medicare|Healthspring","standard_charge_dollar":53.88,"standard_charge_algorithm": "Lesser of $53.88 or 105 Percent of Billed Charges","count":"0","methodology":"fee schedule", "additional_payer_notes": "No services performed during 12-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare|All Other Plans","standard_charge_dollar":56.44,"standard_charge_algorithm": "Lesser of $56.44 or 110 Percent of Billed Charges","count":"0","methodology":"fee schedule", "additional_payer_notes": "No services performed during 12-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare|HMO","standard_charge_dollar":54.39,"standard_charge_algorithm": "Lesser of $54.39 or 106 Percent of Billed Charges","count":"0","methodology":"fee schedule", "additional_payer_notes": "No services performed during 12-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare|PPO","standard_charge_dollar":56.44,"standard_charge_algorithm": "Lesser of $56.44 or 110 Percent of Billed Charges","count":"0","methodology":"fee schedule", "additional_payer_notes": "No services performed during 12-month lookback period."}]}]}],"modifier_information": [{"description": "Bilateral procedure", "code": "50", "modifier_payer_information": [{"payer_name": "BCBS - TN","plan_name": "Commercial|Network S","description": "150% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "United","plan_name": "Medicaid|TennCare","description": "150% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Amerigroup","plan_name": "Medicare|All Plans","description": "150% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Alliant Health","plan_name": "Commercial|All Plans","description": "150% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Centene","plan_name": "Commercial|Ambetter Exchange","description": "150% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "BCBS - TN","plan_name": "Commercial|Network P","description": "150% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Humana","plan_name": "Medicare|All Other Plans","description": "150% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Humana","plan_name": "Medicare|PPO","description": "150% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "BCBS - ND","plan_name": "Medicare|All Plans","description": "150% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Cigna","plan_name": "Medicare|Healthspring","description": "150% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Humana","plan_name": "Medicare|HMO","description": "150% payment adjustment for the item or service to which the modifier is appended"}]},{"description": "Item designated by FDA as Class III Devices", "code": "KF", "modifier_payer_information": [{"payer_name": "Cigna","plan_name": "Medicare|Healthspring","description": "116% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "BCBS - ND","plan_name": "Medicare|All Plans","description": "116% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Amerigroup","plan_name": "Medicare|All Plans","description": "116% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Humana","plan_name": "Medicare|HMO","description": "116% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Humana","plan_name": "Medicare|PPO","description": "116% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Humana","plan_name": "Medicare|All Other Plans","description": "116% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Centene","plan_name": "Commercial|Ambetter Exchange","description": "116% payment adjustment for the item or service to which the modifier is appended"}]},{"description": "Replacement of facial prosthesis including new impression/moulage", "code": "KM", "modifier_payer_information": [{"payer_name": "BCBS - ND","plan_name": "Medicare|All Plans","description": "95% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Cigna","plan_name": "Medicare|Healthspring","description": "95% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Centene","plan_name": "Commercial|Ambetter Exchange","description": "95% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Amerigroup","plan_name": "Medicare|All Plans","description": "95% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Humana","plan_name": "Medicare|PPO","description": "95% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Humana","plan_name": "Medicare|HMO","description": "95% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Humana","plan_name": "Medicare|All Other Plans","description": "95% payment adjustment for the item or service to which the modifier is appended"}]},{"description": "Replacement of facial prosthesis", "code": "KN", "modifier_payer_information": [{"payer_name": "Humana","plan_name": "Medicare|HMO","description": "40% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Humana","plan_name": "Medicare|All Other Plans","description": "40% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "BCBS - ND","plan_name": "Medicare|All Plans","description": "40% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Cigna","plan_name": "Medicare|Healthspring","description": "40% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Amerigroup","plan_name": "Medicare|All Plans","description": "40% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Centene","plan_name": "Commercial|Ambetter Exchange","description": "40% payment adjustment for the item or service to which the modifier is appended"},{"payer_name": "Humana","plan_name": "Medicare|PPO","description": "40% payment adjustment for the item or service to which the modifier is appended"}]},{"description": "Technical component", "code": "TC", "modifier_payer_information": [{"payer_name": "Employers Health Network","plan_name": "Commercial|All Plans","description": "92% payment adjustment for the item or service to which the modifier is appended"}]}],"general_contract_provisions": [ 
{ "payer_name": "Aetna", "plan_name": "Commercial|Gatekeeper", "description": "Inpatient - Reimbursement for the entire encounter may be limited to 100 Percent of Billed Charges" },{ "payer_name": "Aetna", "plan_name": "Commercial|Non-Gatekeeper", "description": "Inpatient - Reimbursement for the entire encounter may be increased by 75 Percent of Billed Charges above 50,000.00 when Billed Charges exceeds a threshold of $50,000.00" },{ "payer_name": "Alliant Health", "plan_name": "Commercial|All Plans", "description": "Inpatient - Reimbursement for the entire encounter may be 64.96 Percent of Billed Charges when Billed Charges exceeds a threshold of $119,185.00" },{ "payer_name": "BCBS - TN", "plan_name": "Commercial|Network P", "description": "Inpatient - Reimbursement for the entire encounter may be increased by 66 Percent of Billed Charges above 320,126.00 when Billed Charges exceeds a threshold of $320,126.00/Inpatient - Reimbursement for the entire encounter may be limited to 100 Percent of Billed Charges" },{ "payer_name": "BCBS - TN", "plan_name": "Commercial|Network S", "description": "Inpatient - Reimbursement for the entire encounter may be increased by 56 Percent of Billed Charges above 297,382.00 when Billed Charges exceeds a threshold of $297,382.00/Inpatient - Reimbursement for the entire encounter may be limited to 100 Percent of Billed Charges" },{ "payer_name": "Centene", "plan_name": "Commercial|Ambetter Exchange", "description": "Inpatient - Reimbursement for the entire encounter may be limited to 100 Percent of Billed Charges" },{ "payer_name": "Cigna", "plan_name": "Commercial|LocalPlus", "description": "Inpatient - Reimbursement for the entire encounter may be increased by 33.6 Percent of Billed Charges above 125,641.00 when Billed Charges exceeds a threshold of $125,641.00/Inpatient - Reimbursement for the entire encounter may be limited to 100 Percent of Billed Charges" },{ "payer_name": "Cigna", "plan_name": "Commercial|Open Access", "description": "Inpatient - Reimbursement for the entire encounter may be increased by 38.9 Percent of Billed Charges above 125,641.00 when Billed Charges exceeds a threshold of $125,641.00/Inpatient - Reimbursement for the entire encounter may be limited to 100 Percent of Billed Charges" },{ "payer_name": "Employers Health Network", "plan_name": "Commercial|All Plans", "description": "Inpatient - Reimbursement for the entire encounter may be 41.63 Percent of Billed Charges when Billed Charges exceeds a threshold of $111,490.00/Outpatient - Reimbursement for the entire encounter may be limited to 100 Percent of Billed Charges" },{ "payer_name": "Health One Alliance", "plan_name": "Commercial|All Plans", "description": "Inpatient - Reimbursement for the entire encounter may be 65 Percent of Billed Charges when Billed Charges exceeds a threshold of $84,365.00/Outpatient - Reimbursement for the entire encounter may be limited to 100 Percent of Billed Charges" },{ "payer_name": "Humana", "plan_name": "Commercial|All Plans", "description": "Inpatient - Reimbursement for the entire encounter may be 65 Percent of Billed Charges when Billed Charges exceeds a threshold of $141,422.00/Outpatient - Reimbursement for the entire encounter may be limited to 100 Percent of Billed Charges" },{ "payer_name": "Multiplan", "plan_name": "Commercial|All Plans", "description": "Inpatient - Reimbursement for the entire encounter may be limited to 100 Percent of Billed Charges/Inpatient - Reimbursement for the entire encounter may be 65 Percent of Billed Charges when Billed Charges exceeds a threshold of $128,274.30" },{ "payer_name": "United", "plan_name": "Commercial|Non-Options", "description": "Inpatient - Reimbursement for the entire encounter may be limited to 100 Percent of Billed Charges" },{ "payer_name": "United", "plan_name": "Commercial|Options", "description": "Inpatient - Reimbursement for the entire encounter may be limited to 100 Percent of Billed Charges" },{ "payer_name": "BCBS - TN", "plan_name": "Medicaid|BlueCare", "description": "Inpatient - Reimbursement for the entire encounter may be limited to 100 Percent of Billed Charges" },{ "payer_name": "United", "plan_name": "Medicaid|TennCare", "description": "Outpatient - Reimbursement for the entire encounter may be limited to 100 Percent of Billed Charges" },{ "payer_name": "BCBS - ND", "plan_name": "Medicare|All Plans", "description": "Inpatient - Reimbursement for the entire encounter may be limited to 100 Percent of Billed Charges" },{ "payer_name": "Cigna", "plan_name": "Medicare|Healthspring", "description": "Inpatient - Reimbursement for the entire encounter may be limited to 100 Percent of Billed Charges" }]}