{"hospital_name":"Logan Health - Cut Bank","last_updated_on":"2026-04-01","version":"3.0.0","location_name":["Logan Health - Cut Bank"],"hospital_address":["802 2Nd St Se, Cut Bank, MT 59427"],"license_information":{"license_number":"13552 ","state":"MT"},"type_2_npi":["1083715791","1831143080"],"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":"Brigid Burke"},"modifier_information":[{"description":"Reference (Outside) Laboratory","code":"90","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Services delivered under an outpatient physical therapy plan of care","code":"GP","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant","code":"CQ","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Modifier description not available","code":"GX<AND>GP","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Modifier description not available","code":"GP<AND>GX","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Bilateral Procedure","code":"50","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Colorectal cancer screening test; converted to diagnostic test or other procedure","code":"PT","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Repeat Clinical Diagnostic Laboratory Test","code":"91","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"State supplied vaccine","code":"SL","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Professional Component","code":"26","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Modifier description not available","code":"GN<AND>95","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Services delivered under an outpatient occupational therapy plan of care","code":"GO","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Modifier description not available","code":"CO<AND>GO","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Modifier description not available","code":"CP<AND>GP","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Modifier description not available","code":"CQ<AND>GP","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Ambulance service furnished directly by a provider of services","code":"QN","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System","code":"95","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Distinct Procedural Service","code":"59","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Right side (used to identify procedures performed on the right side of the body)","code":"RT","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Left side (used to identify procedures performed on the left side of the body)","code":"LT","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Reduced Services","code":"52","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Modifier description not available","code":"52<AND>LT","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Modifier description not available","code":"52<AND>RT","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Modifier description not available","code":"LT<AND>LT","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Modifier description not available","code":"26<AND>RT","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Modifier description not available","code":"26<AND>LT","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Modifier description not available","code":"26<AND>52","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Modifier description not available","code":"52<AND>26","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Modifier description not available","code":"RT<AND>26","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Modifier description not available","code":"LT<AND>26","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Physician assistant service","code":"AN","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"MMAI & MACo Other Commercial Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Allegiance","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Logan Employee","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"EBMS","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"First Choice Health","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Mountain Health Co-op","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"PacificSource","plan_name":"PPO","description":"The modified price is presented in the standard charge value."},{"payer_name":"Tricare West","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"TriWest Healthcare Alliance","plan_name":"Traditional","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"PPO","description":"The modified price is presented in the standard charge value."}]},{"description":"Modifier description not available","code":"D5","modifier_payer_information":[{"payer_name":"6 Degrees of Health","plan_name":"PPO","description":"The modified price is presented in the standard charge 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"11","median_amount":255.5,"10th_percentile":138.59,"90th_percentile":624.63}]}]},{"description":"Level 3 Type A ED Visits","code_information":[{"code":"5023","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Allegiance","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":1032.49,"10th_percentile":1032.49,"90th_percentile":1032.49},{"payer_name":"Bcbs","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Logan Employee","methodology":"percent of total billed charges","standard_charge_percentage":70.0,"count":"1 through 10","median_amount":658.87,"10th_percentile":658.87,"90th_percentile":723.68},{"payer_name":"Bcbs","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":93.0,"count":"94","median_amount":847.58,"10th_percentile":311.47,"90th_percentile":1314.98},{"payer_name":"Ebms","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"12","median_amount":794.95,"10th_percentile":226.95,"90th_percentile":1538.31},{"payer_name":"First Choice Health","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"1 through 10","median_amount":1244.78,"10th_percentile":1244.78,"90th_percentile":1244.78},{"payer_name":"Mountain Health Co-Op","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":92.0,"count":"1 through 10","median_amount":825.13,"10th_percentile":446.38,"90th_percentile":1428.48},{"payer_name":"Pacificsource","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":100.0,"count":"1 through 10","median_amount":855.8,"10th_percentile":855.8,"90th_percentile":855.8},{"payer_name":"Tricare West","plan_name":"Traditional","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Tricare methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"30","median_amount":729.75,"10th_percentile":409.74,"90th_percentile":1335.25}]}]},{"description":"Level 4 Type A ED Visits","code_information":[{"code":"5024","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Allegiance","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":3406.65,"10th_percentile":3406.65,"90th_percentile":3792.65},{"payer_name":"Bcbs","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Logan Employee","methodology":"percent of total billed charges","standard_charge_percentage":70.0,"count":"1 through 10","median_amount":880.3,"10th_percentile":880.3,"90th_percentile":2676.82},{"payer_name":"Bcbs","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":93.0,"count":"43","median_amount":2180.0,"10th_percentile":1262.09,"90th_percentile":5411.2},{"payer_name":"Ebms","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"1 through 10","median_amount":899.33,"10th_percentile":376.11,"90th_percentile":5443.78},{"payer_name":"First Choice Health","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mountain Health Co-Op","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":92.0,"count":"1 through 10","median_amount":2339.66,"10th_percentile":1632.24,"90th_percentile":4320.85},{"payer_name":"Pacificsource","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":100.0,"count":"1 through 10","median_amount":517.97,"10th_percentile":517.97,"90th_percentile":517.97},{"payer_name":"Tricare West","plan_name":"Traditional","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Tricare methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"12","median_amount":2138.35,"10th_percentile":1349.29,"90th_percentile":3118.65}]}]},{"description":"Level 5 Type A ED Visits","code_information":[{"code":"5025","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Allegiance","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaidprovider.mt.gov/]","count":"1 through 10","median_amount":6788.65,"10th_percentile":6788.65,"90th_percentile":6788.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Logan Employee","methodology":"percent of total billed charges","standard_charge_percentage":70.0,"count":"1 through 10","median_amount":1231.01,"10th_percentile":1231.01,"90th_percentile":1231.01},{"payer_name":"Bcbs","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":93.0,"count":"12","median_amount":6265.38,"10th_percentile":5049.2,"90th_percentile":8485.22},{"payer_name":"Ebms","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"1 through 10","median_amount":8846.64,"10th_percentile":8846.64,"90th_percentile":8846.64},{"payer_name":"First Choice Health","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mountain Health Co-Op","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":92.0,"count":"1 through 10","median_amount":1513.72,"10th_percentile":1513.72,"90th_percentile":3815.54},{"payer_name":"Pacificsource","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":100.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Tricare West","plan_name":"Traditional","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Tricare methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"1 through 10","median_amount":2818.63,"10th_percentile":2045.39,"90th_percentile":6831.45}]}]},{"description":"Critical Care","code_information":[{"code":"5041","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Allegiance","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Logan Employee","methodology":"percent of total billed charges","standard_charge_percentage":70.0,"count":"1 through 10","median_amount":235.2,"10th_percentile":235.2,"90th_percentile":235.2},{"payer_name":"Bcbs","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":93.0,"count":"1 through 10","median_amount":271.39,"10th_percentile":87.89,"90th_percentile":271.81},{"payer_name":"Ebms","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Choice Health","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mountain Health Co-Op","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":92.0,"count":"1 through 10","median_amount":471.91,"10th_percentile":471.91,"90th_percentile":502.26},{"payer_name":"Pacificsource","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":100.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Tricare West","plan_name":"Traditional","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Tricare methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Logan Employee","methodology":"percent of total billed charges","standard_charge_percentage":70.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":93.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Ebms","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Choice Health","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mountain Health Co-Op","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":92.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Pacificsource","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":100.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Tricare West","plan_name":"Traditional","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Tricare methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Skin Procedures","code_information":[{"code":"5053","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Allegiance","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaidprovider.mt.gov/]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Logan Employee","methodology":"percent of total billed charges","standard_charge_percentage":70.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":93.0,"count":"1 through 10","median_amount":2193.9,"10th_percentile":2193.9,"90th_percentile":2193.9},{"payer_name":"Ebms","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Choice Health","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mountain Health Co-Op","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":92.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Pacificsource","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":100.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Tricare West","plan_name":"Traditional","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Tricare methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"1 through 10","median_amount":4347.67,"10th_percentile":4347.67,"90th_percentile":4572.59}]}]},{"description":"Level 1 Gynecologic Procedures","code_information":[{"code":"5411","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Allegiance","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Logan Employee","methodology":"percent of total billed charges","standard_charge_percentage":70.0,"count":"11","median_amount":383.78,"10th_percentile":221.2,"90th_percentile":528.15},{"payer_name":"Bcbs","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":93.0,"count":"65","median_amount":449.19,"10th_percentile":237.39,"90th_percentile":833.0},{"payer_name":"Ebms","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"1 through 10","median_amount":358.15,"10th_percentile":306.79,"90th_percentile":890.25},{"payer_name":"First Choice Health","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mountain Health Co-Op","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":92.0,"count":"12","median_amount":375.26,"10th_percentile":281.76,"90th_percentile":678.6},{"payer_name":"Pacificsource","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":100.0,"count":"1 through 10","median_amount":494.28,"10th_percentile":494.28,"90th_percentile":494.28},{"payer_name":"Tricare West","plan_name":"Traditional","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Tricare methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"12","median_amount":310.85,"10th_percentile":271.92,"90th_percentile":474.05}]}]},{"description":"Level 2 Imaging without Contrast","code_information":[{"code":"5522","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Allegiance","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Logan Employee","methodology":"percent of total billed charges","standard_charge_percentage":70.0,"count":"1 through 10","median_amount":531.48,"10th_percentile":229.43,"90th_percentile":2113.51},{"payer_name":"Bcbs","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":93.0,"count":"56","median_amount":592.4,"10th_percentile":319.56,"90th_percentile":1549.85},{"payer_name":"Ebms","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"1 through 10","median_amount":536.88,"10th_percentile":280.13,"90th_percentile":1583.18},{"payer_name":"First Choice Health","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mountain Health Co-Op","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":92.0,"count":"1 through 10","median_amount":469.19,"10th_percentile":243.32,"90th_percentile":996.79},{"payer_name":"Pacificsource","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":100.0,"count":"1 through 10","median_amount":561.02,"10th_percentile":491.85,"90th_percentile":1590.24},{"payer_name":"Tricare West","plan_name":"Traditional","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Tricare methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"13","median_amount":634.6,"10th_percentile":322.01,"90th_percentile":1246.11}]}]},{"description":"Level 3 Imaging without Contrast","code_information":[{"code":"5523","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Allegiance","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Logan Employee","methodology":"percent of total billed charges","standard_charge_percentage":70.0,"count":"1 through 10","median_amount":1330.18,"10th_percentile":996.48,"90th_percentile":1613.68},{"payer_name":"Bcbs","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":93.0,"count":"37","median_amount":2006.71,"10th_percentile":717.73,"90th_percentile":4035.04},{"payer_name":"Ebms","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"11","median_amount":1434.9,"10th_percentile":513.21,"90th_percentile":2885.27},{"payer_name":"First Choice Health","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mountain Health Co-Op","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":92.0,"count":"1 through 10","median_amount":854.33,"10th_percentile":300.21,"90th_percentile":4121.81},{"payer_name":"Pacificsource","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":100.0,"count":"1 through 10","median_amount":2332.91,"10th_percentile":2332.91,"90th_percentile":2332.91},{"payer_name":"Tricare West","plan_name":"Traditional","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Tricare methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"1 through 10","median_amount":1562.64,"10th_percentile":583.16,"90th_percentile":4281.04}]}]},{"description":"Level 4 Imaging without Contrast","code_information":[{"code":"5524","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Allegiance","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaidprovider.mt.gov/]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Logan Employee","methodology":"percent of total billed charges","standard_charge_percentage":70.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":93.0,"count":"1 through 10","median_amount":1816.78,"10th_percentile":1806.99,"90th_percentile":3273.3},{"payer_name":"Ebms","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Choice Health","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mountain Health Co-Op","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":92.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Pacificsource","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":100.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Tricare West","plan_name":"Traditional","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Tricare methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Imaging with Contrast","code_information":[{"code":"5571","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Allegiance","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaidprovider.mt.gov/]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Logan Employee","methodology":"percent of total billed charges","standard_charge_percentage":70.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":93.0,"count":"1 through 10","median_amount":2405.45,"10th_percentile":1900.22,"90th_percentile":5516.78},{"payer_name":"Ebms","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Choice Health","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Mountain Health Co-Op","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":92.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Pacificsource","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":100.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Tricare West","plan_name":"Traditional","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Tricare methodology. Available, referenceable Tricare logic found here: https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/TRICARE-Health-Plan/Rates-and-Reimbursement]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Triwest Healthcare Alliance","plan_name":"Traditional","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Tricare methodology. Available, referenceable Tricare logic found here: https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/TRICARE-Health-Plan/Rates-and-Reimbursement]","count":"1 through 10","median_amount":1784.22,"10th_percentile":1784.09,"90th_percentile":2120.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Imaging with Contrast","code_information":[{"code":"5572","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Allegiance","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":4100.12,"10th_percentile":4100.12,"90th_percentile":4100.12},{"payer_name":"Bcbs","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"1 through 10","median_amount":3941.31,"10th_percentile":3941.31,"90th_percentile":4005.2}]}]},{"description":"Level 2 Drug Administration","code_information":[{"code":"5692","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Allegiance","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"1 through 10","median_amount":1783.02,"10th_percentile":1783.02,"90th_percentile":1783.02}]}]},{"description":"Level 1 Minor Procedures","code_information":[{"code":"5731","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Allegiance","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"1 through 10","median_amount":130.0,"10th_percentile":130.0,"90th_percentile":130.0}]}]},{"description":"Level 4 Minor Procedures","code_information":[{"code":"5734","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Allegiance","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Logan Employee","methodology":"percent of total billed charges","standard_charge_percentage":70.0,"count":"83","median_amount":122.51,"10th_percentile":40.0,"90th_percentile":474.61},{"payer_name":"Bcbs","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":93.0,"count":"360","median_amount":230.88,"10th_percentile":63.12,"90th_percentile":611.72},{"payer_name":"Ebms","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"39","median_amount":262.3,"10th_percentile":75.49,"90th_percentile":751.12},{"payer_name":"First Choice Health","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"1 through 10","median_amount":226.45,"10th_percentile":226.45,"90th_percentile":226.45},{"payer_name":"Mountain Health Co-Op","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":92.0,"count":"62","median_amount":170.11,"10th_percentile":69.47,"90th_percentile":660.07},{"payer_name":"Pacificsource","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":100.0,"count":"25","median_amount":145.75,"10th_percentile":101.75,"90th_percentile":426.86},{"payer_name":"Tricare West","plan_name":"Traditional","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages Tricare methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"87","median_amount":198.74,"10th_percentile":47.55,"90th_percentile":661.92}]}]},{"description":"Therapy Services","code_information":[{"code":"N801","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Allegiance","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":527.02,"10th_percentile":527.02,"90th_percentile":527.02},{"payer_name":"Bcbs","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"17","median_amount":824.36,"10th_percentile":120.0,"90th_percentile":2255.07}]}]},{"description":"Mammography Services","code_information":[{"code":"N804","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Allegiance","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":416.1,"10th_percentile":416.1,"90th_percentile":416.1},{"payer_name":"Bcbs","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Unitedhealthcare","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":95.0,"count":"11","median_amount":416.1,"10th_percentile":88.5,"90th_percentile":416.1}]}]},{"description":"Other Medicine","code_information":[{"code":"N809","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Allegiance","plan_name":"Ppo","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Healthy Montana Kids Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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